mtl)eCttpoflrt»lork 

College  of  ^fjpjiicians!  anb  ^urgeotus 

Hibrarp 


ON    GUNSHOT    INJURIES 
TO    THE    BLOOD-VESSELS, 


ON    GUNSHOT    INJURIES 
TO    THE    BLOOD-VESSELS 

Founded  on  experience  gained  in   France  during 
the  Great  War,   1914-1918. 


GEORGE    HENRY    MAKINS,    G.C.M.G,    C.B. 

President  of  the  Royal  College  of  Surgeojis  of  England ; 

Surgeon  to  St.    Thomas's  Hospital; 

Honorary  I\Tajor-General,  and  late  Senior  Consulting  Surgeon  to  the 

British  E.r^editionary  Force  in  France. 


NEW    YORK: 

WILLIAM    WOOD     AND     COMPANY 

MDCCCCXIX 


PRINTED  IX  ENGLAND  BY 
JOHN  WEIGHT  AND  SONS  LID.,  BRISTOL. 


TO 

MY    SURGICAL    COMRADES    OF 

THE    GREAT   WAR 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/ongunshotinjurieOOmaki 


PREFACE. 

A  GLANCE  at  this  essay  will  suffice   to  show  the  lines  upon  which  it 
has  been  prepared. 

The  General  Section  consists  of  an  amplified  and  revised  edition 
of  several  papers  already  written  upon  the  subject,  while  the  Special 
Section  furnishes  the  material  from  which  the  views  expressed  have 
been  deduced. 

No  attempt  has  been  made  to  deal  with  the  literature  of  the 
subject,  since  it  has  seemed  to  the  author  that  the  individual 
practical  experience  of  one  surgeon  might  be  of  greater  value  than 
opinions  drawn  from  an  examination  of  the  work  of  others. 

It  remains  to  express  the  author's  thanks  to  the  many  surgeons 
who  afforded  him  the  opportunity  of  examining  their  cases — to 
Captain  Bashford  for  his  aid  in  the  description  of  the  histological 
details ;  to  Captain  L.  W.  Shelley  for  his  continuous  help  in  keeping 
up  the  records  of  the  cases ;  to  Captain  Z.  Mennell,  for  help  with 
the  cases  in  London  ;  to  Sir  W.  Morley  Fletcher,  Lieutenant-Colonel 
Elliott,  and  Dr.  M.  Young,  for  the  valuable  aid  given  on  behalf 
of  the  Medical  Research  Committee  in  obtaining  both  recent  informa- 
tion and  later  information  as  to  the  ultimate  results  of  cases ; 
to  Messrs.  A.  K.  Maxwell,  S.  A.  Sewell,  and  J.  R.  Ford,  for  the 
beautiful  illustrations  they  have  prepared  for  the  book;  and,  lastty, 
to  Mr.  S.  H.  Rouquette  for  kindly  reading  most  of  the  i3roof-sheets. 

49,  Upper  Brook  Street, 
March,   1919. 


TABLE   OF    CONTENTS. 


CHAPTER    I. 

Introduction. 


Knowledge   acquired    during    present  war.      Experience    of   recent 
campaigns.     Mode  of  collection  of  observations  dealt  with     -  -  1-5 


CHAPTER    II. 

Distribution,     and     Anatomical      Characters     of     Gunshot 
Wounds  of  the  Blood-vessels. 

Frequency  with  which  the  individual  vessels  are  implicated  :   Deter- 
mining factors.     Contusion  of  the  vessels:    Thrombosis  secondary  to 
contusion.     Varieties    of   woimd  met    with.     Wounds  of  the  veins. -^ 
Mode  of  repair  .......  6-29 


CHAPTER    III. 

Symptoms    and    Signs    of    Gunshot    Injuries    to    the    Blood- 
vessels, and  the  Treatment  of  PLemorrhage. 

General  symptoms.  Local  signs  of  ha;morrhage.  Local  treatment 
of  primary  haemorrhage.  Recurrent  and  secondary  haemorrhage. 
Replacement  of  blood.  Signs  of  interference  with  the  distal 
circulation.  Effects  of  wounds  of  the  vessels  on  the  general 
circulation  :  Cardiac  disturbance — Cardiac  murmurs- — Local  vascular 
murmurs — Transmission  of  local  murmurs  to  heart — Signs  of 
disturbance    of    the    nervous    functions         -  -  -  .         30-56 


CHAPTER    IV. 

Arterial^and  Arterio-venous  H^matomata,  and  Traumatic 
Aneurysms. 

Mode  of  development  of  traumatic  aneurysm. .  Characters  of  sacs. 
Effects  on,  and  changes  in,  surrounding  tissues.  Tardy  develop- 
ment of  aneurysms.  Signs  and  symptoms.  Progress  and  compli- 
cations. Secondary  haemorrhage  and  extension.  Infection  and 
inflammation.  Septic  aneurysms.  Arterio-venous  aneurysms : 
Varieties — Complications — Signs.  Aneurysmal  varix.  Treatment  of 
traumatic  aneurysms  :  Arterial — Arterio-venous — Aneurysmal  varices  57-S6 


CHAPTER     V. 

The  Immediate  and  Remote  Effects  of  Occlusion  of  the 
Main  Blood-vessels  on  the  Vitality  of  the  Parts 
Supplied  by  them. 

Direct  effects   of  anaemia.      Association  with  injury  to  the  nerves. 

Grades  of  signs  of  malnutrition.     Gangrene     -  -  -  -         87-96 


X  CONTENTS 

CHAPTER    VI. 

General  Lines  of  Operative  Treatment. 

Provisional  restraint  of  lKrmorrha<iC  :  Tonrniqnet — Lipatnre.  Types 
of  exploratory  incision.  Siionld  sinniltaneons  ligature  of  artery  and 
vein  be  adopted.  Angciorrhaphy.  Temporary  re-establishment  of 
the  circulation  .  .  .  -  .  .  .       97-111 

CHAPTER    VII. 

The  Great  Vessels  of  the  Trunk. 

Vessels  of  the  chest:  Aorta — Innominate  vessels.  Vessels  of  the 
abdomen  :  Intra-  and  retro-peritoneal  injuries — Abdominal  aorta — 
Iliac  vessels — Prognosis  and  treatment.    Wounds  of  the  great  veins  -     li;j-12f> 

CHAPTER    VIII. 

Vessels  of  the  Neck. 

Carotid  arteries  :  Diagnosis — Complications — Secondary  haemorrhage 
— Contemporaneous  injury  to  nerves — Cerebral  complications — 
Formation  of  traumatic  aneurysms — Treatment  of  injuries  to  the 
carotid  arteries — Mode  of  operation — Prognosis.  Subclavian  artery : 
Nature  of  lesions — Contemporaneous  nerve  injuries — -Prognosis  and 
treatment— Vertebral  artery  ------     127-188 


CHAPTER    IX. 

Vessels  of  the  Upper  Extremity. 

Axillary  artery:  Character  of  injuries — Signs  of  injury  to  the  axillary 
'     vessels — Prognosis  and  treatment — Methods  of  treatment  adopted — 
Mode  of  operation.     Brachial  artery:  Character  of  injuries — Prog- 
nosis   and    treatmeiit.     Vessels    of  the  forearm         -  .  -     189 -SO") 


CHAPTER       X. 

Vessels  of  the  Lower  Extremity. 

Femoral  artery:  Characteristics — -Contusion  and  thrombosis — 
Wounds  of  femoral  vessels — Signs  of  woimds  of  femoral  vessels — 
Hfematomata  in  connection  with  wounds  of  brandies  of  trunks — ■ 
Profimda-: — Circmnflex  —  Prognosis  and  treatment — Gangrene. 
Arterial  lia;matomata  and  aneurysms — Artcrio-venous  aneurysms. 
Aneinysmal  varices  :  Treatment — Ligature — Sutxu'e — Tuflfier's  tube 
■ — General  lines  of  treatment — Remarks  on  ojierative  procedure. 
Femoral  veins.  Pojiliteal  artery  :  Characters  of  injuries — Contusion 
and  thrombosis — Wonnd-. — Complications — Clinical  characteristics — 
Arterial  luematoniata — Arterio-venous  aneurysms — Occurrence  of 
gangrenc^ — Prognosis  and  treatment  —  Ligature — Tuffler's  tube — 
Suture — Operative  procedure.  Arteries  of  the  leg :  Characteristics — 
Signs  of  woinrds  of  the  tibial  vessels — Prognosis  and  treatment     -     208-24(i. 


LIST    OF    ILLUSTRATIONS. 

PLATES. 

PAGE 

I. — Thrombosed  femoral  artery          -             -             -             -             -             -  10 

II. — Slightly  oblique  transverse  section  of  contused  artery    -              -              -  10 

III. — Longitudinal  section  of  contused  artery                 .             .             .             -  10 

IV. — Section  of  a  clot  from  a  TuflRer's  tube      -             -             -             -             -  110 

IN   THE   TEXT. 

FIG.  PAGE 

1. — Wound  of  common  carotid  artery  and  internal  jugular  vein          -             -  2 

2. — Three  types  of  wound  produced  by  bullets  of  small  calibre             -             -  4 

3.^ — Contusion  of  common  iliac  artery              -             -             -             -             -  9 

4. — Rupture   of  internal   and   middle   coats   of  radial   artery   produced   by 

stretching  -------  .g 

5. — Contusion  of  brachial  artery,  lateral  thrombus     -              -              -              -  12 

6. — Aneurysmal  dilatation  of  femoral  artery                 -              -              -              -  14 

7. — Fragment  of  shell  impacted  within  lumen  of  axillary  artery          -              -  16 
8. — ^Types  of  arterial  wounds                 -              -              -              -              -              -17 

9. — Perforating  wounds  of  femoral  artery  and  vein    -              -              -              -  19 

10. — Complete  severance  of  popliteal  artery  and  vein                  -              -              -  20 

11. — Atypical  severance  of  femoral  artery        -             -             -             -             -  21 

12. — Complete  severance  of  popliteal  vein,  thrombosis  of  popliteal  artery       -  23 

13. — Perforation  of  common  iliac  vein                -              -              -              -              -  24 

14. — Section  of  wound  of  popliteal  vein              -              -              -              -              -  25 

15. — Spontaneous  healing  of  axillary  artery     -              -              -              -              -  27 

16. — Impacted  bullet  in  popliteal  vessels          -             -             -             -             -  28 

17. — Skiagram    showing    position    of    heart    during    inspiration.     Popliteal 

arterio-venous  aneurysm          -             -             -             -             -             -  42 

18. — Skiagram    showing    position     of    heart    during    expiration.     Popliteal 

arterio-venous  aneurysm           -              -              -              -              -              -  43 

19. — Skiagram    showing    position    of    heart    during    inspiration.     Disorderly 

action  of  heart              -             -             -             -             -             -             -  44 

20. — Skiagram    showing    position    of   heart    during    expiration.       Disorderly 

action  of  heart               -              -              -              -              -              -              -  45 

21. — Wound  of  common  carotid  artery,  provisional  thrombus,  and  clot  without 

vessel  -  -  -  -  -  -  -  -58 

22. — Three  small  aneurysmal  sacs  in  the  early  stage  of  formation           -              -  59 

23. — Section  of  wall  of  aneuiysmal  sac               -             -             -             -             -  59 

24. — Septic  aneurysm  from  amputation  stump               -              -              -              -  68 

25. — Diagram  of  different  types  of  arterio-venous  aneurysms  -              -              -  69 

2G. — Wounds  of  popliteal  artery  and  vein         -             -             -             -             -  72 


xii  LIST    OF    ILLUSTRATIONS 

FIG.                   •  PACK 

27. — Aneuiysmal  varix  of  ooinnioii  caiolid  artery  and  intc  rnal  juffular  vein  -  7(5 
28. — Diagrammatie  rcprcscntatinn  of  union  of  artery  and  vein  in  a  femoral 

aneinysnial   \arix          -                            -              -              -              -              -  77 

29. — Spontaneously  licaled  aneurysmal  vaiix                  -              -              -              -  79 

30. — Wounds  of  eommon  earotid  artery  and  internal  jugular  \(in,  imohcinent 

of  vagus             -              -              -              -              -              -              -              -  HO 

31. — Comparative  effects  of  ligature  of  artery  alone,  and  of  artery  and  vein. 

on  the  intestine  of  the  cat      -  -  -  -  -  -]().■> 

32. — Spherical  ball  lodged  in  thoracic  aorta       -              -              -              -              -  113 

33.^ — Bidlet  woimd  of  thoracic  aorta     -              -              -              -              -              -  11-i 

34. — Bilateral  perforation  of  abdominal  aorta                 ....  i2] 

35. — Arterial  hsematoma,  common  iliac  artery                -              -              -              -  124! 

36. — Pulsating  exophthalmos                    .._..-  p29 

37. — External  carotid  aneurysm              -              -              -              -              -              -  131 

38. — Arterio-venous  injury  of  common  carotid  artery                  -              -              -  133 
39. — Mesial  section  of  neck,  gas  in  retropharyngeal  space.     Anaerobic  infec- 
tion                     -              -              -              -              -              -              -              -134 

40. — Wound  of  common  carotid,  retained  fragment  of  shell  .  .  -  140 
41. — Contusion    of    common    carotid,    progressive    thrombosis    extending    to 

cerebral  arteries  -  -  -  -  -  -  -141 

42. — Carotid  aneurysm  laid  open,  showing  arterial  openings  into  sac    -              -  159 

43. — Exposure  of  internal  jugular  vein  in  an  arterio-venous  aneurysm               -  166 

44. — Bilateral  injury  to  carotid  arteries,  implication  of  right  vagus  nerve         -  170 

45. — Common  carotid  aneurysm              _.....  172 

46.^ — -Wounds  of  vessels  in  aneurysm  shown  in  Fig.  45                 .              .              -  173 
47. — Aneurysm   of  subclavian  artery   --              -              -              -              -182 

48. — Skiagram  showing  foreign  body  which  had  woimded  sidjclavian  vessels  183 

49. — Arterial  aneurysm  of  second  part  of  the  axillary  artery     -              -              -  192 

50. — Skiagram  of  foreign  body  on  chest  wall  -----  194 

51. — Exposed  axillary  aneurysm             -              -              -              -              -              -  198 

52. — Wounds  of  axillary  vessels  -  -  -  -  -  -199 

53. — Wound  of  brachial  artery,  formation  of  secondary  anevnysm        -              -  203 

54. — Wounds  of  eommon  and  deep  femoral  arteries      -              -              -              -  211 

55. — Arterio-venous  aneurysm  of  femoral  artery            -              -              -              -  213 

56. — Ai'terio-venous     aneurysm     in     connection     with     woinidcd     circmnHex 

artery                 -              -              -              -              -              -              -              -  210 

57. — Arterio-venous  aneurysm  of  superficial  femoral  artery       -              -              -  222 

58. — Skiagram  of  retained  shrapnel  ball  .  -  .  -  -  224 
59. — Skiagram  showing  antero-posterior  view  of  fragment  of  shrapnel   ease 

which  had  wounded  the  popliteal  vessels         -              -              -              -  232 

60. — Lateral  view  of  fragment  shown  in  skiagram  (J'/g.  59)       -             -             -  232 


GUNSHOT 
INJURIES    TO    THE    BLOOD-VESSELS. 


CHAPTER    I. 
INTRODUCTION. 


WOUNDS  the  main  importance  of  which  depends  upon  imph- 
cation  of  the  large  vascular  trunks,  and  their  consequences, 
have  been  a  subject  of  special  interest  in  the  treatment  of 
gunshot  injuries  for  all  time.  Knowledge  as  to  the  general  behaviour 
exhibited  by  these  lesions  has  undergone  little  material  change. 
Their  special  features,  consisting  in  the  tendency  to  spontaneous 
cessation  of  primary  haemorrhage  even  in  the  presence  of  very 
extensive  damage  to  the  vessel  involved  ;  the  frequency  with  which 
such  forms  of  injury  are  the  occasion  of  secondary  haemorrhages  ; 
and  the  large  pro]3ortion  of  them  which  are  followed  by  the  develop- 
ment of  one  of  the  several  forms  of  traumatic  aneurj^sm,  have  been 
maintained. 

The  chief  information  gained  during  the  present  war  will  be 
found  to  consist  in  a  more  accurate  knowledge  of  the  signs  of  injuries 
to  the  arteries  ;  such  as  the  indications  to  be  gleaned  from  an 
examination  of  the  peripheral  and  vasomotor  nervous  system  ;  the 
value  of  auscultation,  both  local  over  the  artery,  and  of  the  precordial 
region  ;  and  as  to  the  actual  mode  of  development  of  some  of  the 
consequences  of  arterial  injuries.  Further,  opportunity  has  been 
afforded  of  jvidging  of  the  effect  of  obliteration  of  the  main  vessels 
upon  the  vitality  of  the  parts  supplied  by  the  peripheral  branches 
affected,  the  latter  observations  being  far  from  exhaustive  at  present. 
An  increase  in  exact  cognizance  of  the  nature  of  the  primarj^ 
anatomical  lesions  of  the  vessels,  and  the  arrangement  of  the  vessels 
in  relation  to  the  various  forms  of  traumatic  aneurysm,  has  been 
acquired.  Lastly,  experience  has  been  gained  as  to  the  relative 
advantages  attained  by  obliteration  of  the  main  vessels  by  ligature,  by 
simultaneous  occlusion  of  artery  and  vein,  and  the  attempt  to  main- 
tain their  viability  by  suture,  respectively.  In  the  latter  particular 
military  practice  has  been  affected,  as  in  so  many  other  fields  of 
surgery,  by  the  limitations  imposed  by  the  septic  nature  of  the  wounds 
to  be  dealt  with.     Hence  primary  or  early  suture,  which  method  was 

1 


GUNSHOT    IXJililES    TO    THE    nLOOD-VESSELS 


Fig.  1. — Lateral  wound  of  common  carotid,  partly  closed  by  clot.  Complete 
division  of  internal  jugular  vein.  Peninsular  War,  Mr.  Guthrie.  Museum  of  Royal 
Army  Medical  College. 


INTRODUCTION  3 

looked  forward  to  with  enthusiasm  in  the  early  part  of  the  war,  had 
to  be  abandoned  for  a  considerable  period,  and  has  only  been  resorted 
to  with  greater  frequency  since  improvements  in  general  treatment 
of  wounds  have  been  attained. 

Fig.  1  is  inserted  to  illustrate  an  injury  received  during  the 
Peninsular  War,  which  differs  in  no  material  respect  from  hundreds 
of  those  which  are  being  met  with  in  the  present  campaigns.  The 
clean,  complete  division  of  the  internal  jugular  vein,  now  closed  by 
an  organizing  thrombus  ;  the  irregular  lateral  wound  of  the  common 
carotid  artery  with  thickened  margins,  almost  occluded  by  a  firm 
fibrinous  clot  ;  and  the  fact  that  the  patient  from  whose  body  the 
specimen  was  removed  died  on  the  twenty-fourth  day  as  a  result  of 
repeated  secondary  hfcmorrhages  from  an  infected  wound,  first 
occurring  on  the  thirteenth  day,  form  a  sufficiently  familiar  picture 
of  conditions  which  more  active  primary  treatment  is  happily 
reducing  steadily  to  greater  rarity. 

The  long  period  of  peace  antecedent  to  the  South  African 
campaign  of  1899-1902  had  greatly  limited  personal  experience  of 
gunshot  injuries  to  the  great  vessels,  this  being  for  the  most  part 
confined  to  occasional  pistol  or  rifle  bullet  wounds  and  the  somewhat 
similar  lesions  produced  by  stabs  by  sharp  instruments.  The  advent 
of  the  Boer  War,  however,  again  brought  a  considerable  number  of 
vascular  injuries  into  the  purview  of  the  military  surgeon.  The 
Lee-Metford  and  Mauser  bullets,  as  a  consequence  of  their  outline, 
stability  and  velocity  of  flight,  proved  themselves  pre-eminenth'^ 
capable  of  effectuating  clean  perforations  or  limited  local  lesions  of 
narrow  structures  such  as  the  blood-vessels.  This  capacity,  indeed, 
was  shown  to  be  so  great  as  to  allow  the  perforation  of  such  vessels 
as  the  tibials,  themselves  of  considerably  smaller  calibre  than  the 
bullet  which  traversed  the  artery. 

Fig.  2  illustrates  a  series  of  injuries  of  this  class  obtained  during 
the  Russo-Japanese  war  in  Manchuria.  It  should  be  observed  that 
the  specimens  from  which  the  illustrations  Avere  taken  are  those  of 
vessels  excised  secondarily  ;  hence  the  margins  of  the  openings  are 
infiltrated  and  thickened,  and  the  perforation  shown  in  («)  has 
acquired  the  rigid  rounded  outline  characteristic  of  the  opening- 
communicating  with  the  cavity  of  an  aneurysmal  sac.  If  exposed 
in  the  recent  state  while  the  artery  still  retains  its  normal  longi- 
tudinal elasticity  and  freedom  from  fixation  to  surrounding  structures, 
such  a  perforation  is  much  more  likely  to  assume  the  appearance 
of  a  simple  vertical  slit,  or  the  entry  wound  may  be  rounded  and 
the  exit  of  slit  form,  as  is  the  case  with  Avounds  of  the  skin  when  a 
limb  is  traversed. 

In  the  present  war  the  emj^loyment   of  every  ancient  form   of 


4         GUNSHOT   INJURIES    TO    THE   BLOOD-VESSELS 

missile  :  llu'  introduction  ol"  liiyh  ex]ilosivcs  and  the  consequent 
inllucncc  on'  the  outline  and  velocity  oi'  llit>ht  of  fraomcuts  of  shells 
and  bombs  ;  together  with  the  comparative  iustability  of  flight  of 
the  modern  pointed  rifle  and  machine-gun  bullet  ;  have  considerably 
modified  the  natiu-e  and  severity  of  the  vascular  lesions  met  with. 
The  chief  alterations  in  character  are  found  in  an  augmentation  of 
the  degree  and  extent  of  contusion,  and  an  increase  of  the  lunviber 
of  what  maj'^  be  considered  incised  and  lacerated  woimds. 

It  is  convenient  in  this  introduction  to  give  a  brief  account  of 
the  manner  in  which  the  material  upon  which  the  present  essay  is 
founded  was  obtained,  and  as  to  how  far  the  conclusions  arrived 
at  are  supported  by  facts. 


Fig.  2. — Bullet  injuries,  (a)  Perforation  of  anterior  tibial  artery,  (b)  Lateral 
wound  of  brachial  artery,  vein  divided,  (c)  Lateral  wound  of  brachial  artery  and 
vein.     Brentano. 

The  small,  number  of  reports  dealing  with  the  primary  treatment 
of  arterial  wounds  have  been  furnished  to  me  by  the  kindness  of 
surgeons  working  at  casualty  clearing  stations.  They  would  have  been 
much  more  comprehensive  had  it  not  been  for  the  imfortiuiate 
accident  that  a  large  number  went  astra}^  during  the  change  which 
took  place  in  the  British  line  in  March,  1918.  None  the  less  I  owe 
a  debt  of  gratitude  to  the  officers  who  gathered  the  information,  and 
to  Lieut. -Colonel  T.  R.  Elliott  and  the  Medical  Research  Committee, 
who  provided  the  necessary  forms  and  organized  their  collection. 

The  results  given  in  these  reports  are  of  an  immediate  nature 
only,  and,  as  a  rule,  the  period  for  which  the  cases  were  imder 
continuous    observation   did   not   average   more  than  a  Aveek  or  ten 


INTRODUCTION  5 

days.  It  has  not  been  possible  to  trace  the  rurther  course  of 
these  patients. 

The  whole  of  the  rest  of  the  niatei'ial  has  been  collected  by 
myself  with  the  aid  of  Captain  L.  W.  Shelley  in  hospitals  on  the  lines 
of  communication,  and  diu'ing  the  past  five  months  at  a  base  hospital 
in  London.  The  cases  included  have  therefore,  without  exception, 
come  under  my  personal  observation,  although  in  a  number  of  them 
I  have  been  in  no  way  responsible  for  the  methods  of  treatment 
adopted. 

For  information  as  to  idtimate  results  I  am  again  indebted  to 
the  Medical  Research  Committee,  and  the  aid  of  Dr.  Matthew  Young. 

It  follows  from  this  account  that  the  difiiculty  common  to  all 
surgical  observations  made  during  war,  which  can  never  be  fully 
avoided — that  of  not  being  able  to  watch  the  progress  of  individual 
cases  from  beginning  to  end — has  been  in  some  measure  overcome  ; 
and  that,  although  the  ideal  has  not  been  attained,  yet  a  fair  general 
review  of  the  course  taken  by  the  injiu'ies  and  the  results  of  treatment 
has  been  secured.  In  the  matter  of  ]3ure  statistics  relatively  small 
reliance  can  be  placed  upon  the  data  furnished ;  yet,  as  the  experience 
of  an  individual  surgeon  they  may  have  their  use,  and  it  has  seemed 
well  to  include  such  numbers  as  are  available,  adding  a  caution  as  to 
the  manner  in  which  they  have  been  collected. 

One  further  remark  seems  necessary.  This  refers  to  the  influence 
which  extended  experience  on  the  one  hand,  and  imjDrovement  in 
wound  treatment  generally  on  the  other,  have  exercised  on  the  course 
taken  b}^  the  cases.  In  January,  1916,  I  published  a  short  review 
of  the  vascular  injuries  observed  by  me  during  the  first  twelve  months 
of  war,  and  I  have  quoted  these  in  places  where  they  differ  materially 
from  those  of  the  more  extended  series  now  dealt  with. 


CHAPTER    IT. 

DISTRIBUTION  AND    ANATOMICAL    CHARACTERS  OF   GUNSHOT 
INJURIES    TO    THE    BLOOD-VESSELS. 

CONDITIONS  WHICH  AFFECT  THE  ACTUAL  FREQUENCY  WITH  WHICH 
THE  INDIVIDUAL  LARGER  ARTERIES  SUFFER  INJURY. 

An  accurate  determination  of  this  question  is  not  easy,  because 
lesions  of  the  great  vessels  which  undergo  treatment  are  recorded  in 
large  niuiibers,  "svhile  those  of  the  smaller  ones,  even  of  the  magnitude 
of  the  tibials,  are  more  frequently  passed  over  as  of  minor  inii^ortance. 
Again,  the  paucity  of  recorded  examples  of  wounds  of  the  great 
arteries  of  the  trunk,  independently  of  the  visceral  vessels,  affords 
eloquent  testimony  to  the  gravity  of  such  injuries  and  their  frequent 
fatal  issue.  With  regard  to  the  large  vessels  of  the  neck  and  limbs 
material  does  exist,  both  as  to  the  individual  arteries  and  to  the 
portions  of  the  vessels  most  likely  to  be  imiDlicated. 

In  a  series  of  169  traimiatic  aneurysms  which  developed  in 
connection  with  wounds  of  the  larger  arteries  collected  bj'  me  in 
1913,  the  niuiibers  are  as  follows.  In  this  series  it  must  be  remem- 
bered that  all  the  injuries  treated  b}^  primary  ligature  have  been 
eliminated.* 

per  cent 


Common  carotid     . 

7 

4-1 

External  carotid     . 

3 

1-5 

Internal  carotid 

1 

0-5 

Subclavian 

4 

2-3 

Axillary    .  . 

23 

13-6 

Brachial    .  . 

21 

12-4 

Femoral    .  . 

.  .        77 

45-5 

Profunda .  . 

5 

2-9 

Popliteal  .  . 

28 

16-5 

Total      .  .      169 

A  valuable  comparison  with  these  mmibers  may  be  drawn  from 
the  next  table,  recording  the  number  of  injiu'ies  to  individual  blood- 
vessels dealt  Avith  at  a  casualty  clearing  station  during  the  earh-^  days 
of  the  first  battle  of  the  Somme,  collected  by  Captain  Hey,  and 
published  by  Sir  Anthony  Bowlby.f 


*  Bradshaw  Lecture,  "Gunshot  Wounds  of  the  Arteries,"'   1913,  p.  32. 
■\  British  Medical  Journal,  1917,  .June,  vol.  i,  p.  707. 


DISTRIBUTION    AND    ANATOMICAL    CHAILUTFJiS      7 


Carotid 

5 

flf.T  Cf.W 

1-8 

Vertebral .  . 

2 

0-7 

Subclavian 

2 

0-7 

Axillary    .  . 

15 

5-4 

Brachial    .  . 

89 

14-2 

Radial 

18 

0-4 

Ulnar 

8 

2-8 

External  iliac 

2 

0-7 

Femoral    .  . 

51 

18-4 

Popliteal     .  . 

31 

11-1 

Anterior  tibial 

16 

5-7 

Posterior  tibial 

58 

20-9 

Various     .  . 

30 

10-8 

Total 


277 


The  most  striking  difference  in  these  two  series  is  the  large  number 
of  injuries  to  the  posterior  tibial  vessels  included  in  the  second  table. 
In  the  next  table  the  small  number  of  injuries  to  this  artery  will  again 
be  noted,  and  it  is  obvious  that  this  discrepancy  depends  on  the  fact 
that  injuries  to  the  posterior  tibial  are,  with  few  exceptions,  dealt  with 
in  the  primary  stage,  and  most  often  in  connection  with  comjDOund 
fractures  or  large  open  wounds. 


per  cent 

Aorta 

2 

0-4 

Carotid 

87 

17-5 

Vertebral 

3 

0-6 

Subclavian 

30 

6-0 

Axillary    .  . 

61 

12-2 

Brachial    . . 

47 

9-45 

Common  iliac 

1 

0-2 

External  iliac 

3 

0-6 

Internal  iliac 

1 

0-2 

Femoral    .  . 

.      175 

35-2 

Popliteal  . . 

87 

17-6 

Total    . 

497 

Tibials  *    .  . 

26 

These  nimibers  demonstrate  sufficiently  the  influence  of  length, 
calibre,  and  location  in  exposed  positions  on  the  proportionate 
incidence  in  the  various  vessels. 

Factors  of  equal  importance  determine  the  more  frequent  location 
of  injury  to  definite  segments  of  the  individual  arteries.  These  factors 
are  found  in  the  relative  degree  of  fixity  of  the  vessels  in  different 
parts  of  their  course,  and  in  their  relation  to  neighbouring  bones. 
First,  with  regard  to  local  fixation  of  the  vessels,  this  depends  upon  : 
(1)  The  width  and  capaciousness  of  the  vascular  cleft,  and  the  amount 
of  loose  connective  tissue  situated  therein;  (2)  The  position  of  branches, 
especially  those  taking  a  direct  course  from  the  parent  artery  at  a 


*  The   injuries   to    the   tibial    vessels    are    not    included    in    the   percentage 
calculation  for  reasons   oiven  above. 


8         GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

wide  angle,  or  those  at  onee  acquiring  a  lirni  connection  witli  a  bone  ; 
and  (3)  On  the  passage  of  the  vessel  luider  a  firm  fibrous  structure. 
Examples  of  contrast  of  the  first  condition  are  fomid  in  the  relative 
fixity  of  the  femoral  vessels  in  Scarpa's  triangle  and  Hunter's  caiuil 
respectively  ;  yet  in  Scarpa's  triangle  the  artery  has  an  important 
anchor  where  the  profunda  dips  sharjDly  beneath  the  adductor  longus, 
and  is  further  immobilized  by  the  origin  of  the  circumflex  branches. 
Familiar  examples  of  the  second  condition  are  the  circumflex  branches 
of  the  axillary  arter}'-,  and  the  upjDer  articular  and  azygos  branches  of 
the  jDopliteal  artery.  The  third  condition  is  met  with  where  the 
femoral  vessels  leave  Hunter's  canal  to  become  popliteal,  and  again 
when  the  posterior  tibial  passes  beneath  the  fibrous  arch  in  the  origin 
of  the  soleus.  The  close  relationshij:)  of  a  large  artery  to  the  neigh- 
bouring part  of  the  skeletoii  is  again  nowhere  better  exemplified  than 
in  the  case  of  the  termination  of  the  femoral  and  the  commencement 
of  the  popliteal  to  the  femur. 

Any  of  the  foregoing  conditions,  as  limiting  or  rendering  impossible 
displacement  of  the  vessel  by  the  expanding  force  exercised  by  the 
travelling  bullet,  may  be  an  all-important  factor  in  preventing  the 
escape  of  the  vessel  from  a  wound  or  serious  contusion. 

CONTUSIONS  OF  THE  BLOOD-VESSELS  CAUSED  BY  GUNSHOT  INJURY. 

Of  the  experience  gained  in  the  present  war,  that  regarding  the 
frequency  of  occurrence  of  contusions,  and  the  significance  of  this 
form  of  injury  in  the  causation  of  thrombosis,  secondary  hamorrhage, 
and  traumatic  aneurysms,  is  perhaps  the  most  novel ;  for  any  accu- 
rate knowledge  that  we  possessed  on  this  subject  previously  Avas 
founded  mainly  on  experimental  studies. 

That  the  condition  was  familiar — as  is  the  ease  with  so  many 
observations  made  in  this  war — to  militar}"  surgeons  in  older  times,  is 
sufficiently  illustrated  by  a  specimen  preserved  by  Mr.  Guthrie,  now 
in  the  museum  of  the  Royal  Army  Medical  College  (No.  34.5).  This 
preparation  shows  the  femoral  vessels  to  be  totall}^  occluded  as  the 
result  of  the  passage  of  a  bullet  by  a  track  coiu'sing  immediately 
behind  them.  It  was  perhaps  too  commonly  assumed  that  the 
thrombosis  in  such  cases  was  a  secondary  result  accompanying 
suppuration,  bvit  the  condition  was  well  known  in  civil  practice 
independent  of  infection.  Thus  I  have  seen  both  popliteal  arteries 
occluded  as  a  result  of  the  passage  of  a  cart-wheel  over  the  limbs, 
the  injury  being  folloAAcd  by  gangrene  of  one  leg  necessitating  amputa- 
tion, when  the  condition  was  confirmed  by  direct  investigation. 

The  following  description  is  founded  in  2:)art  on  clinical  observa- 
tion, and  in  part  on  the  beautiful  histological  preparations  made  for 
me  by  Captain  Rashford. 


DISTRIBUTION   AND    ANATOMICAL    CHARACTERS      9 

The  degree  and  extent  of  damage  to  the  walls  of  the  vessels  may 
vary  greatly,  and  it  is  most  important  to  remember  that  mere  inspec- 


Fig.   3. — Contusion  of   right    common    iliac    artery  :    internal    and    external    surfaces. 
Linear  rupture  of  the  intiraa  and  minute  perforation.     Captain  Adrian  Stokes. 

tion  of  the  exposed  vessel  often  gives  but  little  idea  of  the  struetural 
disintegration  that  has  been  effected,  and  also  that  the  mischief  mav 

mm 


Fig.  jk. — Section  of  radial  artery,  showing  a  rupture  of  the  intima  involving  the 
muscularis,  discovered  one  inch  from  a  small  contused  perforating  womid.  Specimen 
prepared  by  Captain  Fringle. 

extend  widely  within  the  vessel  from  the  spot  wliere  the  external 
indications  are  strongest. 


10  GlXSllOT    IXJi  HIES    TO    THE    BIJJOD-VESSELS 

Figs.  3  and  4  exhibit  wliat  may  be  reoarded  as  tlic  most  limited 
degree  of  structiiral  damage.  In  Fig.  3  two  ccchymosed  areas  are 
visible  on  the  outer  aspeet  of  the  common  iliac  artery,  -while  on  the 
inner  aspect  a  linear  rupture  of  the  intima,  probably  also  involving 
the  miiscxilaris,  is  visible.  In  the  recent  state,  when  removed  by 
Cai^tain  Adrian  Stokes  from  the  body  of  a  man  who  died  as  a  result 
of  injuries  to  the  abdominal  viscera,  the  neighliourhood  of  the 
rupture  was  clothed  by  a  delicate  network  of  clot,  forming  a  thin 
lateral  thrombus. 

Fig.  4  shows  a  lesion  consisting  of  a  linear  fissure  involving 
the  intima,  the  internal  elastic  lamina,  and  half  the  dei)th  of  the 
muscidaris.  The  rupture  was  associated  with  a  perforating  lesion 
situated  an  inch  lower  down  in  the  course  of  the  vessel,  and  no  external 
indication  of  its  presence  existed.  It  will  be  observed  that  even  the 
microscopic  section  affords  no  evidence  of  local  blood  extravasation 
into  the  walls  of  the  vessel.  The  specimen  is  illustrative  of  the  fact 
that  remote  ruptures  of  the  intima  and  imderlying  coats  may  be  due 
to  stretching  of  the  vessel  consequent  on  forcible  displacement  from 
its  bed  rather  than  to  local  contusion. 

Plate  I  (A)  gives  an  external  view  of  a  thrombosed  segment 
of  the  superficial  femoral  artery  excised  by  Major  Hope  from  the 
floor  of  a  large  open  wound  on  the  anterior  aspect  of  the  thigh. 
Secondary  haemorrhage  occurred  on  the  tenth  day,  and  necessitated 
this  operation.  At  the  upper  part  of  the  drawing  two  small  dark 
spots  are  seen  ;  these  correspond  to  the  jDoints  of  maximal  structural 
injury,  and  at  one  of  them  the  artery  had  given  way  and  allowed  the 
bleeding  to  take  place.  Plate  I  {B),  from  a  section  carried  through  the 
clot  across  these  spots,  shows  well  how  very  much  more  extensively 
the  coats  of  the  vessel  are  damaged  than  could  have  been  estimated 
from  external  inspection  alone.  Every  degree  of  structural  disinte- 
gration which  may  accompany  severe  contusion  is  exhibited — thus, 
disappearance  of  the  endothelium  from  the  portion  of  the  vessel 
occupied  by  the  clot,  rupture  of  the  elastic  lamina%  fissuring  of  the 
muscularis  to  varying  depths,  and  one  fissure  completely  dividing  the 
nniscularis  and  allowing  the  escajDC  of  blood  into  the  adventitia.  No 
evidence  of  infection  of  the  clot  could  be  detected. 

All  these  changes  are  illustrated  in  greater  detail  by  Plates  II 
and  ///,  made  from  preparations  by  Captain  Bashford,  to  A\hom  I 
am  indebted  for  the  histological  particulars.  The  vessel,  an  anterior 
tibial  artery  still  pervious  and  pulsating,  was  excised  by  Captain 
Hartley  from  the  floor  of  an  ojDcn  womid  in  the  front  of  the  leg  as  a 
precautionary  measiu'c,  since  it  had  obviously  been  damaged.     Plate 

11  is    of    a   slightly  oblique   transverse   section   of  the   vessel.      The 
adventitia  is  normal  at  the  lower  part  of  the   figiu'e  except  for  some 


PLATE     I. 


(A) — Thrombosed  segment  removed  from  superficial  femoral  artery.  The  upper  of 
the  two  dark  spots  corresponds  with  the  point  from  which  secondary  hajmorrhage  took 
place.  The  lower  of  the  two  dark  spots  is  the  outward  manifestation  of  the  extensive 
haemorrhage  within  the  destroyed  or  necrosed  adventitia,  a  portion  of  which  is  shown 
displaced  in  the  figure.  In  several  other  sections  it  was  found  to  be  continuous  with 
the  tissue  above  and  below  by  a  thin  membrane  covering  the  extravasated  blood. 

(B) — Longitudinal  section  through  the  contused  vessel  shown  in  (A).  Multiple 
ruptures  of  the  intima  and  media.  Extravasation  into  the  adventitia.  At  one  point 
the  adventitia  has  necrosed  and  given  way  and  allowed  the  occurrence  of  secondary 
hamorrhage. 


Gvmhut  Injuries  to   the   Vlood-i-essch-,  j).  10 


PLATE     II. 


r'-'pSJCS.^; 


Slightly  oblique  transverse  section  across  a  contused  artery.  A,  Adventitia  ; 
B,  External  elastic  lamina;  C,  Media.  ;  D,  Internal  elastic  lamina,  destroyed  in  \ipper 
part  of  figure  ;  E.  Thickened  sub-endothelial  layer ;  F,  Hsemorrhage  into  adventitia; 
G,   Extreme  thinning  of  media  at  point  of  maximal  injury. 


Gunshot  Iitjiirii's  to   the  Blood-ressels,  p.  10 


PLATE     HI. 


---7--D 


Longitudinal  sectioii  of  the  same  artery  shown  in  Plate  II.  Complete  dis- 
organization of  wall  of  vessel  on  left  side.  E,  Remains  of  adventitia  infiltrated 
with  leucocytes.  Right  side  :  A,  Internal  elastic  lamina.  B,  Irregular  nucleation  and 
some  vacuolation  of  cells  of  media.     C,   Normal  adventitia. 


Gunxlwt  Injuries  to    Ihe  Blood-vcsieU,  ji.  10 


DISTRIBUTION    AND    ANATOMICAL    CIIARACTKRS    11 

leucocytic  infiltration,  and  an  interstitial  blood  extravasation  in  the 
upper  part.  Both  the  external  and  the  internal  elastic  laminae  are 
fairly  intact  in  the  lower  part  of  the  section,  showing  their  normal 
ciu'ves,  but  in  the  upper  half  the  elastic  tissue  is  stretched,  straight- 
ened out,  and  fissured.  I'he  muscular  coat  gradually  thins  from  the 
normal  part  to  the  point  of  maximal  contusion  (G),  where  it  has 
almost  disappeared,  and  in  the  upper  part  of  the  section  a  consider- 
able amount  of  leucocytic  infiltration  has  taken  place.  The  sub- 
endothelial  layer  is  irregularly  thickened,  and  the  endothelial  lining- 
is  gone.  The  lumen  of  the  vessel  is  occupied  by  a  clot,  the  peripheral 
layers  of  which  are  evidently  of  slow  formation,  while  the  central 
portion  consists  of  clot  of  more  rapid  formation,  which  encloses  a 
small  cavity  occupied  by  blood  platelets  and  fibrin. 

A  vertical  section  of  the  vessel,  the  lower  end  of  which  corresponds 
with  the  level  at  which  the  transverse  section  was  made,  is  shown  in 
Plate  III.  It  will  be  noted  that  the  adventitia  is  completely  dis- 
organized on  the  left  side  of  the  figure  ;  it  is,  in  fact,  only  recognizable 
at  the  upper  jDart,  and  is  heavily  infiltrated  Avith  leucocytes  and  some 
fibrin.  On  this  side  of  the  artery  both  the  elastic  lamina:;  are  com- 
pletely destroyed,  and  an  extensive  deposit  of  fibrin  takes  the  place  of 
the  endothelium  and  sub-endothelial  tissue.  The  right-hand  wall  of  the 
vessel  is  less  damaged,  and  its  normal  structure  is  fairly  well  retained. 
The  adventitia  is  normal ;  the  cells  of  the  media  show  some  vacuola- 
tion  and  disarrangement  of  the  nuclei,  but  are  not  seriously  affected. 
The  internal  elastic  lamina  is  recognizable  throughout  :  as  fibres 
below,  but  its  membranous  structure  is  recognizable  above.  The 
sub-endothelial  tissue  is  thickened  and  irregularly  nucleated,  and  the 
place  of  the  endothelium  is  taken  by  a  layer  of  fibrin.  The  central 
clot  exhibits  the  same  characters  already  described  in  the  oblique 
section. 

The  common  sequence  to  contusion  of  the  wall  of  the  vessel  is 
a  rapid  thrombosis  ;  this  may  remain  localized,  or  it  may  extend 
progressively  in  a  peripheral  direction.  It  is,  however,  remarkable 
that  rapid  thrombosis  is  by  no  means  an  inevitable  consequence, 
even  when  the  contusion  is  of  the  degree  depicted  in  Plate  II.  In  this 
artery  pulsation  was  still  present  on  the  fourth  day  following  the 
injury,  although  the  vessel  was  exposed  and  its  external  appearance 
led  the  surgeon  to  tie  it  and  excise  the  injured  portion.  The  section 
shows  what  had  reall}^  taken  place — the  immediate  formation  of  a 
thrombus  not  sufficiently  large  to  obstruct  the  lumen  of  the  vessel, 
and,  later,  the  deposition  of  a  more  fibrinous  layer  of  clot  uj^on  this. 
A  later  figure  {Fig.  21,  p.  58)  depicts  a  central  cjdindrical  thrombus 
in  connection  with  a  wound  in  the  wall  of  the  vessel,  which  w^as  only 
sufficiently  capacious  partially  to  obstruct  the  lumen,  and  Fig.  5  shows 


12        GUXSIIOT    IXJIHIES    TO    TIIK    BLOOD-VESSELS 

a  lateral  firm  thrombus,  also  not  causing  complete  obstruction.  The 
signilicancc  of  sucli  thrombi  in  relation  to  tlie  possible  detachment 
of  emboli  is  obvious.  No  doubt  the  tendency  of  these  thrombi  is  to 
become  comjiletely  obstructive.  The  common  course  is  for  them  to 
remain  local  in  extent  ;  less  frequently  the  clot  ma}^  extend  widely  in 
a  peripheral  direction,  and  some  instances  of  this  will  be  referred  to 
later,  cspeciall}^  in  connection  with  the  carotid  artery. 


Fig.    6. — Contusion    of   the    Brachial   Artery,   with    Incomplete   Laceration 

OF  THE  Walls    of  the  Vessel. 

The   adventitia  is   ruptured,   the   muscularis   ahnost  intact,   and   the    intima   broken. 

Over  the  damaged  jjortion  of  the  intima  a  local  lateral  thrombus  has  developed. 

It  is  evident,  in  the  case  of  the  partially  obstructing  thrombi 
figured,  that  the  process  started  from  the  most  seriously  damaged 
portion  of  the  vessel,  and  should  the  whole  circumference  suffer,  the 
formation  of  a  completely  occluding  clot  is  more  rapid  ;  but  even  in 
such  instances  the  clot  may  by  no  means  tightly  fill  the  vessel,  and  in 
spite  of  its  presence  blood  may  escape  in  small  quantities.  Thus  in 
one  case  a  very  severely  damaged  artery  is  described  by  Major 
Copeland  as  looking  "as  if  it  had  been  rubbed  by  a  nutmeg  grater," 
and  blood  was  slowly  escaping  at  several  distinct  spots. 

A  point  of  some  importance  is  illustrated  in  Fig.  21,  with  regai'd 
to  the  possibility  of  persistency  of  the  hmien  of  a  vessel  primaril}^ 
completely  occluded  by  a  thrombus.  Sir  A.  AVright,  many  years 
ago,  pointed  out  the  small  proportion  of  the  corpuscular  element  and 
the  abiuidance  of  fibrin  in  the  clots,  also  the  tendency  to  rapid 
contraction  of  the  fibrinous  network  and  shedding  of  the  retained 
red  blood-corpuscles.  Early  firm  adhesion  of  the  clot  occurs  only 
at  the  site  of  the  wound  or  contusion  of  the  Avail  of  the  artery,  and 
the  clot  contracts  towards  this  anchored  point.  Hence  the  huiien 
becomies  in  part  re-established,  and  in  the  absence  of  renewed  deposi- 
tion of  clot  viability  of  the  vessel  may  be  more  or  less  completely 
regained. 

The  tendency  to  ra]:)id  clotting  ma,y  no  doubt  differ  in  association 
Avith  conditions  of  the  blood,  but  that  slow  progressive  occlusion  is 
a  common  occurrence  seems  to  be  indicated  b}^  the  gradual  manner 
in  which  occlusion  may  follow  the  operation  of  sutiu'c,  although,  on 
the  other  hand,  a  thrombus  may  form  before  a  sutm'e  operation  has 
been  comj^leted  b}^- closure  of  the  main  wound.     It  is  doubtful  also 


DISTRIBUTION    AND    ANATOMICAL    CIIAHACTKRS    Vi 

whether  the  varying  rapidity  with  which  a  Tiillicr's  tube  becomes 
occhided,  altogether  corresponds  with  the  technical  ca})acity  witli 
which  it  has  been  introduced. 

The  accidents  Hable  to  follow  arterial  thrombosis  in  gvuishot 
injuries  are  identical  with  those  common  to  the  condition  under  other 
circumstances.  Primary  rapid  occlusion  may  give  rise  to  anamic 
gangrene,  which  may  be  immediate,  and  is  strictly  comparable  with 
that  which  follows  the  interruption  of  the  blood  supply  by  ligature  of 
the  vessel.  The  occurrence  of  gangrene  is  naturally  favoured  in  cases 
in  which  the  clot  formation  extends  peripherally.  This  accident  has 
been  most  commonly  observed  to  take  place  in  the  carotid,  femoral, 
and  popliteal  arteries.  When  the  process  of  occlusion  is  partial  or 
less  rapid  in  nature,  time  is  allowed  for  compensatory  changes  in  the 
collateral  circulation,  and  the  effects  are  less  serious  ;  but  still  the 
vitality  of  the  parts  situated  in  the  area  of  the  peripheral  distribution 
of  the  vessel  may  suffer  in  the  same  manner  as  after  the  apj^lication 
of  a  ligature.  Definite  iscba!mic  changes  may  develo^D,  or  the  muscles 
lose  considerably  in  volume  and  contractile  power.  These  changes 
are  naturally  most  marked  when  an  associated  injury  to  the  nerves 
is  present,  but  they  occur  in  some  degree  whenever  the  peripheral 
circulation  is  interfered  with. 

The  occurrence  of  embolism  in  these  injuries  must  be  considered 
quite  apart  from  the  question  of  septic  infection  and  disintegration 
of  the  clot  :  portions  of  soft  recent  clot  may  become  detached  and 
cause  trouble  from  the  sudden  and  complete  anaemia  produced.  The 
same  remark  applies  to  the  occurrence  of  secondary  haemorrhage,  the 
bleeding  being  the  result  of  the  normal  separation  of  the  devitalized 
area  of  tissue  in  the  vessel  wall.  The  clot  in  the  case  illustrated  in 
Plate  I  was  not  infected,  and  the  tissue  of  the  arterial  wall  shows 
little  sign  of  reactionarj^  changes. 

There  can  be  no  question  that  injuries  of  the  nature  of  contusions 
and  non-perforating  lacerations  are  not  infrequently  the  explanation 
of  the  late  formation  of  aneurysms  or  hsematomata.  The  corresj^ond- 
ence  of  the  date  at  which  pulsation  and  swelling  appear  in  many  cases, 
with  that  at  which  .secondary  hemorrhage  is  common,  is  in  itself 
suggestive.  Beyond  this,  however,  many  operators  have  observed 
local  bulging  of  arteries  at  the  time  of  explorations  for  hfcmorrhage. 
A  characteristic  description  is  given  in  a  report  by  Captain  Cowell 
in  which  he  says  the  inner  coats  of  the  artery  bulged  through  a  defect 
in  the  adventitia,  like  an  inner  bicycle  tube  projecting  through  a 
hole  in  the  cover.  Small  local  bulges  may  also  indicate  injury  to 
the  inner  layers  of  the  wall.  Fig.  6  depicts  such  a  bulge  in  the 
fenaoral  artery  above  the  opening  of  an  arterio- venous  communication. 
Dilatation  of  the  entire  lumen  may  also  result  in  the  earh^  stages  of 


14        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

an  arterial  injury.     7*^?^.  53  shows  an  early  stage  of  aneurysm  forma- 
tion from  a  leak  in  the  centre  of  a  contused  area  of  the  brachial  artery. 
Thrombosis  as  a  result  of  contusion  is  still  more  commonly  seen 
in  the  veins  than  in  the  arteries.     The  condition  is  often  met  "svith 
during  the  performance  of  o^aerations  on  wounded  arteries,  and  the 
observation    that    pre-existing    blocking   of   the 
[-gr-  .gj.  vein  in  no  way  prejudiced    the   results    of   liga- 

r'l  turc  of  a  main  artery,   was  one  of  the    circum- 

I  stantial  facts  which  sujiportcd   the  introduction 

of  the  practice  of  ligaturing   both  vessels  when 
occlusion  of  the  artery  is  necessary. 

The  existence  of  a  contusion  of  the  arterial 
^vall  is  not  readily  determined,  in  the  absence 
of  ocular  demonstration.  The  sign  which  com- 
monly suggests  its  occurrence,  obliteration  of  the 
peripheral  pulse,  may  equally  denote  a  contused 
suture  of~superficiai  lateral  w^ouud  or  cvcu  complete  severance  of  the 
femoral  artery.    Small      artery,     Cascs  liavc  also  bccu  recorded*  in  which 

aneurysmal  dilatation.  ,         ,  .  .      i     i  i  n    ,  i 

Litrature    of    femoral      explorations    Suggested    by  absence  oi   the  peri- 
'^'^"^-  pheral  pulse  have  revealed  no  appreciable  lesion, 

Veau  ascribes  this  occurrence  to  a  state  of 
general  vaso-constriction  of  the  artei'ies  of  the  limb,  and  designates 
the  condition  arterial  stupor.  It  would  seem  to  correspond  to 
the  condition  of  local  shock  which  accounts  for  the  temporary  loss 
of  sensation  and  power  in  a  limb  the  subject  of  a  gunshot  injury. 
Its  chief  interest  seems  to  lie  in  affording  a  possible  explanation  in 
some  cases  of  the  absence  of  ha:>morrhage  from  completely  divided 
arteries  \ying  exposed  in  an  open  Avound,  and  such  a  condition  might 
possibly  be  concerned  in  the  occTu-rence  of  the  immediate  cerebral 
symptoms  which  may  follow  injury  to,  or  ligature  of,  the  carotid 
arteries. 

The  subject  of  arterial  thrombosis  cannot  be  left  without  mention 
of  the  very  serious  influence  which  rapid  blocking  of  the  main  arter)'', 
or  even  of  minor  branches,  may  exert  on  the  rapid  progress  of  anaerobic 
gangrene.  This  subject  has  been  ably  dealt  with  by  Captain 
Bashfordt  in  his  paper  on  the  general  pathology  of  acute  bacillarv 
gangrene  arising  in  gunshot  injuries  of  muscle,  which  supplies  both 
clinical  and  histological  evidence  of  the  manner  in  which  the  rapid 
extension  of  the  i:)rocess  is  favoured   by  Aascular  obstruetioji.     The 


*  MM.    Veau,   Viannev,    Lacoste,    and    Fereier,    Presse    Medicale,    1918. 
No.  46,  Aug.  l.>,  p.  42.J. 

■[British  Journdl  of  Siugcrij  vol.  iv,  Xo.  16,  p.  587. 


DISTRIBUTION  AND    ANATOMICAL    CHARACTERS     15 

influence  of  blocking  of  the  visceral  arteries  upon  the  organs  concerned 
has  also  been  dealt  with  by  Captain  Bashford*  in  a  paper  on  the 
histology  of  the  tissues  immediate  and  remote  from  the  point  of  injury 
in  gmishot  wounds  ;  and  by  Colonel  Andrew  Fullertonf  in  the  case 
of  the  kidney. 

GUNSHOT   WOUNDS   OF  THE   BLOOD-VESSELS. 

Wounds  of  either  arteries  or  veins  may  be  divided  into  three 
classes:  (1)  Lateral  wounds,  transverse,  vertical,  or  oblique; 
(2)  Perforations  traversing  the  lumen  of  the  vessel ;  (3)  Complete 
severances  of  continuity.  Practically  every  one  of  these  lesions  is  of 
a  contused,  or  contused  and  lacerated,  character.  Mr.  Shattockf  has 
pointed  out  that  in  no  instance  amongst  a  large  series  of  wounded 
vessels,   could   any  evidence  of  explosive  effect  be  detected. 

Lateral  Wounds. — These  lesions  may  be  of  the  most  insignificant 
character,  or,  on  the  other  hand,  may  be  of  a  more  serious  nature  than 
even  a  complete  division. 

The  least  serious  lesions  are  those  caused  by  punctures  by  minute 
fragments  of  metal,  such  as  may  be  derived  from  portions  of.  the 
mantle  of  a  fragmented  bullet,  or  small  particles  of  bombs.  The 
fragment  may  enter  the  lumen,  be  arrested  in  the  opposite  wall  of 
the  vessel,  or  pass  into  the  blood-stream.  No  doubt  many  such 
lesions  undergo  spontaneous  repair,  and  their  occurrence  may  not 
even  be  suspected  ;  but  instances  occur  in  which  the  opening  remains 
patent  and  an  aneurysm  develops.  Inspection  from  within  the 
cavity  of  the  sac  in  such  cases  arouses  surprise  that  patency  could 
have  been  maintained.  The  possession  of  a  minute  orifice  of  entry 
such  as  this  no  doubt  explains  some  of  the  cases  of  spontaneous  cure 
of  traumatic  aneurysm  which  occur. 

A  foreign  body,  even  of  the  size  of  a  bullet,  may  enter  by  a  lateral 
wound  and  thence  travel  in  the  interior  of  the  vessel.  An  instance 
in  which  a  bullet,  entering  by  the  thoracic  aorta,  passed  on  to  be 
arrested  in  the  right  common  iliac  artery  is  quoted  on  p.  115.  In 
another  remarkable  case  a  shrapnel  ball  lying  in  the  lumen  of  the 
inferior  vena  cava  was  apparently  maintained  in  position  below  the 
opening  in  the  diaphragm  by  the  force  of  the  blood-stream. 

Fig.  7  illustrates  an  incomplete  lateral  wound,  or  it  might  be 
regarded  as  an  attempt  at  perforation,  abortive  as  a  consequence  of 
want  of  force  on  the  part  of  the  missile.     In  this  instance  a  fragment 


*  liritisJi  Journal  of  Surgery  vol.  iv,  No.  15,  p.  433. 
t  Ibid.,  vol.  V,  No.  18,  p.  248. 

J  Proceedings   of  the   Royal  Society  of  Medicine  1918.  vol.   xi,  No.   9,   Jiilv. 
p.  116. 


16        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

of  shell  now  lies  impacted  within  the  lumen  of  the  axillary  artery  and 
comi^letely  obstructs  it.  It  is  probable  that  in  the  initial  stage  the 
small  missile  failed  to  perforate  the  intima,  and  pushed  this  before 

it  imtil  the  blood-stream  was  com- 
pletely interrupted.  Subsequently 
the  media  and  advent  it  ia  have 
healed  spontaneously  over  the  outer 
aspect  of  the  piece  of  metal,  and 
the  intima  has  perished,  leaving 
Firj.  7.  — Impacted  foreign  body  in      ^-j-^g    foreign    bodv    surrouiidcd    bv 

tlie  axillary  artery.  ® 

{Coio7wi  Charters  Symonds.)  organized     thrombus     ^\ithiu     the 

lumen  of  the  vessel. 

The  tjqDcs  and  degrees  of  lateral  lesions  are  portrayed  in  the 
various  examples  included  in  Fig.  8.  All  were  drawn  from  arteries 
removed  after  a  sufficient  lapse  of  time  to  allow  of  stiffening  and 
fixation  from  infiltration  of  the  wall  of  the  vessel  ;  hence  the  orifices 
are  patent  and  gaping.  In  a  more  recent  condition  the  openings 
gape  less  widely,  the  margins  are  generally  irregularly  shredded,  the 
tattered  adventitia  projecting  around  the  stoma,  while  the  museularis 
and  intima  are  more  or  less  retracted.  Histological  examination  shows 
the  structure  of  the  adjacent  part  of  the  wall  of  the  artery  to  have 
suffered  injury  similar  to  that  described  under  the  heading  of  contusion, 
extending  over  a  variable  area.  A  number  of  illustrations  of 
lateral  wounds  will  be  found  in  the  sections  devoted  to  the  special 
vessels. 

The  specimen  lettered  c  in  Fig.  8  illustrates  diagrammatically 
a  type  of  wound  met  with  on  one  occasion  ;  its  form,  that  of  a  lateral 
flap,  is  of  some  importance  with  regard  to  the  possibility  of  the 
restraint  of  haemorrhage  by  pressure  of  extravasated  blood-clot  on 
the  artery  from  without.  This  Avoimd,  as  also  those  marked  a,  b,  and 
e,  may  be  regarded  as  examples  of  more  or  less  purely  incised  wounds 
produced  by  the  passage  of  small  sharp  fragments  of  metal.  Given 
satisfactory  local  and  aseptic  conditions,  all  are  eminently  suitable  for 
treatment  by  suture.  In  dealing  with  such  lesions,  however,  it  has 
to  be  constantly  borne  in  mind  that  the  structural  damage  to  the  wall 
of  the  artery  may  be  much  more  extensive  than  the  external  appear- 
ances would  seem  to  Avarrant,  since,  beyond  the  visible  laceration, 
remote  injiu'ies  to  the  museularis  and  intima  may  have  resulted  from 
contusion  and  stretching  at  the  time  of  the  accident.  The  actual 
patent  opening  may  in  fact  lie  in  the  centre  of  an  area  of  the  Avail  of 
the  vessel,  in  Avhich  contusion  has  led  to  Avidespread  structural  dis- 
integration such  as  is  portrayed  in  Plate  III.  These  remote  injuries, 
although  perhaps  not  sufficient  to  cause  failure  of  luiion  of  the 
line  of  sutiu-e,  are  yet   capable  of  A'itiating  the  final    result   of   the 


DISTRIBUTION    AND    ANATOMICAL    CHARACTERS    17 


Fig.  8. — Types  of  Arterial  Wounds. 


/ 


a.  Small  portion  of  the  femoral  artery  removed  at  the  time  that  the  aneurysm 
was  extirpated  and  the  vessel  ligatured,  with  the  piece  of  shell  which  produced  the 
injury.  The  regular  outline  and  smooth  margins  of  such  an  incised  wound  at  the  end 
of  ten  days  are  well  shown. 

h.  Oval  wound  of  superficial  femoral  artery.  The  wound  is  in  iiumediate  proximity 
to  a  lateral  branch  fixing  the  artery.     Shell  injury. 

c.  Diagrammatic  representation  of  a  flap-like  wound  of  subclavian  artery.  Large 
mass  of  j)riniary  clot  ;  no  aneurysmal  sac  formed  ;  secondary  cellulitis  of  neck  ; 
secondary  haemorrhage.     Shell  injvirj^ 

d.  Oval  wound  of  superficial  femoral  artery.  The  thin  strip  of  arterial  wall 
between  the  main  opening  and  the  lateral  slit  shows  this  to  have  been  actually  a 
perforation.  Secondary  hsemorrhage  appears  to  have  taken  place  through  the  lateral 
slit.     The  specimen  has  become  bent  during  the  process  of  preparation.     Bullet  injury. 

e.  Unusually  long  lateral  wound  of  axillary  artery.  Note  the  branch  arismg 
immediately  opposite  the  centre  of  the  wound. 

/.  Diagrammatic  representation  of  a  three-fifths  division  of  the  femoral  artery. 
This  form  is  frecjuent,  and  amounts  practically  to  a  complete  division  of  the  vessel. 
It  is,  however,  a  more  serious  injury,  since  the  reinaining  bond  of  union  prevents  free 
retraction  and  contraction  of  the  ends,  and  hence  spontaneous  thrombosis  and  closui'e 
of  the  vessel  is  less  likely  to  take  place. 

It  will  be  noted  that  all  these  vessels  were  exposed  from  three  to  ten  days  after 
the  infliction  of  the  wound  ;  hence  the  margins  of  all  are  more  even  and  rounded 
than  in  the  recent  stage  of  the  injuries. 


18       GUNSHOT    IXJUNIES    TO    THE    BLOOD-VESSELS 

operation   by   favourinti'   the   occurrence   of    tlirombosis   and   ultimate 
occlusion. 

When  a  larger  proportion  of  the  circumference  of  the  vessel  is 
involved,  or  if  actual  loss  of  substance  has  been  extensive,  the  degree 
of  retraction  of  the  ojDcn  ends  of  the  artery  is  often  ver}^  great, 
reaching  a  maxinuun  in  such  injuries  as  Fig.  8,  /.  In  such 
circumstances  the  conditions  are  further  distorted,  as  has  been 
pointed  out  by  Sencert,*  by  a  change  in  the  axis  of  the  remaining 
strand  of  the  wall  of  the  vessel.  This  band  forms  a  salient  angle  at 
the  extremities  of  which  the  open  ends  of  the  vessel  point  in  the  same 
diverging  line.  As  a  result  of  this  arrangement,  the  open  ends  of 
the  vessel  deliver  the  stream  of  blood  in  a  false  direction,  while  the 
connecting  strand  prevents  their  retraction  into  the  tissues,  and  thus 
haemorrhage  is  favoured.  When  the  degree  of  retraction  is  less,  the 
wound  itself  forms  the  blunt  apex  of  the  salient  angle.  In  a  later 
stage  the  open  ends  of  the  vessel  cicatrize,  the  intima  and  adventitia 
uniting  over  the  retracted  media,  and  a  rounded  smooth  opening  is 
formed  communicating  with  a  false  aneurysm  (see  Fig.  42,  p.  159). 
I  believe  it  is  rare  for  spontaneous  closure  of  the  vessel  to  take  place 
in  injuries  of  this  class. 

Consideration  of  the  series  of  woimds  illustrated  above  and  the 
accomi^anying  remarks  on  their  anatomical  characters,  makes  it 
evident  that  no  useful  practical  distinction  can  be  drawn  between 
wounds  of  the  arteries  caused  by  bullets  or  fragments  of  shells  as 
far  as  indications  for  treatment  are  concerned.  It  is  clear,  on  the  one 
hand,  that  a  shell  wound  may  be  either  limited  and  incised  in 
character,  or  a  severely  contused  and  lacerated  injury  ;  on  the  other, 
that  while  the  modern  pointed  bullet,  given  direct  and  exact  impact, 
may  cause  a  limited  and  strictly  localized  lesion,  it  is  also  capable, 
in  consequence  of  its  inherent  instability  of  flight,  of  adding  an  ex- 
tensive area  of  contusion  around  any  opening  it  may  effectuate.  Each 
injury,  in  fact,  requires  to  be  judged  on  the  actual  condition  disclosed 
on  direct  examination,  and  not  upon  the  nature  of  the  agent  which 
produced  it,  always  bearing  in  mind  the  greater  probabilities  of  serious 
infection  of  the  neighbouring  soft  tissues  in  lesions  produced  by 
fragments  of  shells. 

Perforations. — This  denomination  is  reserved  for  those  injiu'ies 
in  which  the  missile  traverses  the  vessel,  and  bilateral  openings  are 
produced.  Excejit  that  the  openings  tend  to  partake  of  the  characters 
of  entry  and  exit  apertiu-es,  that  of  entry  being  of  a  punchcd-out 
natiu'e,  and  that  of  exit  stretched  and  everted,  little  ]iractical  distine- 


Lcs  Blcssiires  des   ]'aisseaiix  (Horizon  Scries),  p.  4. 


DISTRIBUTION    AND    ANATOMICAL    CIIARACTKKS    19 

tion  can  be  drawn  between  thcnr  and  many  of  the  lateral  wounds 
already  described.  This  form  of  injury  may  be  caused  by  either 
bullets,  or  fragments  of  shells,  or  bombs.  The  modern  change  in 
outline  and  balance  has  rendered  pure  perforations  by  bullets  of  less 
frequent  proportionate  occurrence.  The  diminution  has,  however, 
been  in  great  measiu'e  made  up  for  by  the  increase  in  number  of 
perforations  effected  by  small  fragments  of  metal  from  shells  and 
bombs  propelled  by  high  explosives. 

Perforations  made  by  the  passage  of  Mauser  or  Lee-Metford 
bullets  are  usually  small  and  gape  little  ;  this  may  also  be  the  case 
with  the  pointed  bullet  if  it  strikes  exactly  and  with  a  low  degree  of 
velocity  (see  skiagram,  Fig.  16)  ;  but  more  frequently  the  margins  of 
the  opening  in  the  vessel  are  considerably  contused,   and  larger  in 


Fig.  9. — Perforating  wound  of  femoral  artery  and  vein.  Adhesion  of  the  opposing 
sides  of  the  vessels  has  established  a  direct  arterio-venous  communication.  Opening 
in  artery  with  irregular  shredded  margins,  that  in  vein  more  incised  in  character. 
Shell  injiiry. 


diameter  than  the  bullet  which  produced  the  injury.  The  actual 
amount  of  gaping  may  be  materially  influenced  by  the  degree  of  local 
fixation  of  the  vessel  and  the  relative  capacity  allowed  for  longitudinal 
stretching.  The  varying  character  and  outline  of  the  openings  may 
be  gathered  from  inspection  of  Fig.  9,  and  in  general  they  may 
differ  little  from  many  of  the  single  lateral  wounds. 

A  remarkable  asymmetrical  perforation  produced  by  a  bullet  is 
illustrated  by  Fig.  8,  d ;  in  this  the  separation  between  the  two 
openings  is  represented  by  a  very  narrow  strip  of  the  arterial  wall. 
The  lesion  obtains  somewhat  special  importance  in  that  the  presence 
of  the  narrow  strip  was  held  by  Colonel  Gordon  "Watson  to  be 
responsible  for  the  separation  of  the  wall  of  a  traumatic  aneurysmal 


20        aiSSIIOT    IX.JIRIES    TO    THE    BLOOD-VESSELS 

sac  at  its  attaclunciit  to  tliis  jioiiit.  aiul  a  consequent  secondary 
ha-niorrhage. 

Fig.  9,  depicting  a  traversing  perforation  of  the  femoral  artery 
and  vein  effected  by  a  fragment  of  shell,  offers  an  excellent  exam])le 
of  the  contrast  between  the  anatomical  characters  exliibited  by  Avomids 
of  arteries  and  veins  respectively,  and  the  greater  tendency  of  tlie 
former  to  be  torn  and  shredded.  A  free  flap  like  that  here  depicted 
may  sometimes  be  met  with  projecting  into  an  arterio-venous 
communication.  I  have  seen  this  on  more  than  one  occasion.  Refer- 
ence to  Fig.  28,  which  shows  a  projecting  flap  of  muscularis  still 
unhealed  in  the  margin  of  an  arterio-venous  communication,  explains 
the  long  jjcrsistence  of  this  condition. 

Complete  Division  of  the  Vessel. — Complete  severance  of  con- 
tinuity of  the  vessels  is  not  imcommon.  In  large  lacerated  wounds 
the  condition  is  easy  of  explanation  ;  but  the  frequent  occiu'rence  of 
complete  solutions  of  continuity  met  with  in  simple  bullet  wounds, 
with  t3q:)ical  apertures  of  entry  and  exit  on  the  surface  of  the  body, 
was  one  of  the  surprises  attendant  upon  the  introduction  of  the  bullet 
of  small  calibre. 

The  anatomical  characters  exhibited  by  the  vascular  wounds  are 
inconstant.  Severances  effected  by  rifle  bullets  sometimes  offer  an 
appearance  difficult  to  distinguish  from  those  made  by  the  knife  of 
the  surgeon,  the  ends  of  the  vessel  appearing  sharp  and  even.  In 
many  of  these  lesions  division  of  the  vessel  is  folio w-ed  by  prompt 
retraction,  of  the  free  ends,  and  spontaneous  cessation  of  or  entire 
escape  from  haemorrhage  occurs,  the  accident  being  followed  neither 
by  the  escape  of  blood  nor  the  formation  of  a  ha?matoma. 


Fi(j.  10. — Complete  division  of  popliteal  artery  and  vein.  The  proximal  end 
of  the  artery  is  thrombosed,  but  was  still  leaking.  The  vein  Ls  completely  occluded, 
but  the  thrombus  does  not  reach  its  free  extremity. 

Completely  divided  arteries  have  often  been  found  in  tlie  course 
of  explorations  made  Avith  a  view^  to  dealing  with  injured  nerve  trunks 
in  which  no  evidence  of  previous  hcX-morrhage  has  been  detected, 
beyond  at  most  a  certain  amount  of  cicatricial  tissue  ;  moreover,  it 
is   often   imiiossiblc  in   practice  to  determine   from   clinical   evidence 


DISTRIBUTION    AND    ANATOMICAL    CHARACTERS    21 


I 


whether  an  absent  radial  pulse  at  the  Avrist  depends  on  contusion 
and  thrombosis  of  the  axillary  artery,  or  complete  severance  of  the 
trunk.  This  difficulty  may  arise  in  wounds  traversing  the  area 
occupied  by  any  of  the  great  vessels  at  the  root  of  the  neck,  the 
axilla,  or  elsewhere,  and  it  arises  with  some  frequency. 

Completely  divided  vessels,  even  of  the  size  of  the  femoral,  are 
often  found  in  large  open  wounds  also,  the  free  ends  contracted  in 
calibre  for  a  short  distance,  and  pulsating  freely  above,  while  no  escajjc 
whatever  of  blood  is  taking  place. 

Fig.  10  depicts  the  condition  of  a  completely  divided  popliteal 
artery  and  vein  found  exposed  in  a  large 
wound.  In  this  case  the  proximal  ex- 
tremity of  the  artery  is  filled  by  a  cylin- 
drical thrombus  which  projects  from  the 
open  lumen.  The  clot  is  seen  to  increase 
gradually  in  calibre  from  above  down- 
wards, and  the  free  extremity  is  dome- 
shaped.  The  form  of  the  thrombus 
depends  upon  the  fact  that  it  did  not 
firmly  o'cclude  the  artery,  and  hence 
leaking  haemorrhage  caused  a  gradual 
increase  in  its  size.  The  satellite  vein  is 
filled  by  a  more  efficient  thrombus,  the 
situation  of  which  is  indicated  by  a 
fusiform  enlargement  seen  above  the  free 
extremity.  It  will  be  observed  that  no 
essential  difference  in  appearance  exists 
between  the  lines  of  section  effected  by 
the  bullet  and  the  knife  of  the  surgeon 
respectively. 

A  striking  contrast  to  these  neat 
injuries  is  not  infrequently  met  with  in 
the  contused  and  lacerated  wounds  caused 
by  rough  fragments,  of  shells.  In  these 
the  free  extremities  of  the  vessel  may  be 
irregularly  torn  and  tattered,  the  division 
of  the    individual    coats    departing    from 

the  ordinary  rule,  and  considerable  lengths  of  the  artery  may  have 
been  actually  carried  away  by  the  passing  missile.  An  example  is 
offered  in  Fig.  11  of  the  thoroughly  atypical  manner  in  which  the 
coats  of  the  artery  may  be  destroyed,  for  here  we  find  a  more  or 
less  intact  tube  of  intima  projecting  from  the  irregularly  torn, 
retracted,  and   rolled-up   muscularis  and  adventitia. 

Speaking   generally,    from    the    point  of    view    of   danger    from 


4-K-/1. 


Fig.  11. — Complete  division 
of  femoral  artery.  Laceration 
of  adventitia  and  media. 
Intima  projecting  with  intact 
circumference  and  regular 
margin. 

Captain  Adrian  Stokes. 


22       GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

hcTmorrhage,  comj^lctc  .sc^'crancc  of  the  vessel  may  be  regarded  as 
a  less  serioiis  accident  than  a  three-quarter  severance  such  as  is 
depicted  in  Fig.  8,  /,  since  in  the  latter  the  bond  of  union  acts  as 
a  check  to  the  normal  process  for  spontaneous  closiu'e  of  the  hmien. 
It  may,  moreover,  be  pointed  out,  that  lesions  of  the  latter  class 
are  apt  not  infrequently  to  be  regarded  as  complete  divisions  when 
met  Avith  in  operations  for  arterial  ha^matoma  or  false  tramiiatic 
anemysm,  because  the  connecting  band,  as  a  result  of  infiltration 
and  fusion  of  the  remains  of  the  artery  with  the  surrounding  tissues, 
becomes  difficult  of  definition  and  recognition. 


WOUNDS    OF    THE   VEINS. 

What  has  been  said  regarding  wounds  of  the  arteries  holds  good, 
in  general,  for  those  of  the  veins  also.  Such  "\-ariation  as  exists 
depends  on  the  more  delicate  and  tenuous  structure  of  the  walls,  and 
on  the  greater  tendency  to  thrombosis. 

]\Iany  of  the  figures  illustrate  these  points,  notably  Fig.'i.  9,  10, 
12.  and  13.  Fig.  10  furnishes  an  example  of  a  very  clean  transverse 
division,  while  in  Fig.  12  a  more  frayed  and  tattered  tear  is  depicted  ; 
in  the  case  of  the  latter  the  condition  is  exaggerated  by  the  adhesion 
of  the  infiltrated  perivenous  areolar  tissue,  as  this  specimen  was 
removed  after  an  interval  of  some  days  from  the  reception  of  the 
injury,  and  secondary  changes  have  taken  place. 

The  differences  dependent  upon  the  smaller  proportion  of 
muscular  tissue,  and  the  lesser  degree  of  resistance  offered  by  the 
vein  to  the  passage  of  the  missile,  are  jDcrhaps  still  better  illustrated 
by  the  characters  exhibited  by  traversing  perforations.  These  are 
wtII  shown  side  by  side  in  Fig.  9,  while  F^ig.  13,  drawn  from  a  speci- 
men obtained  by  Captain  Adrian  Stokes,  affords  an  excellent  example 
of  a  simple  traversing  wound  of  the  common  iliac  vein  in  which  little 
secondary  change  took  place  prior  to  the  death  of  the  patient.  The 
openings  in  this  drawing  gape  widely,  but  when  the  slits  are  vertical 
the  tendency  diu'ing  life  is  for  the  vein  to  collapse  somewhat  and  the 
margins  of  the  w'ound  to  fall  together.  Many  instances  of  perforations 
or  rents  of  the  great  veins  at  the  back  of  the  abdominal  cavity  have 
been  recorded,  in  Avhich  haemorrhage  was  arrested  spontaneously  or 
by  the  aid  of  the  surgeon,  where  recovery  from  the  injury  followed. 
A  good  instance  of  such  an  injiuy  to  the  portal  vein  treated  by  forci- 
pressure  has  been  recorded  by  Captain  Romanis.*  Diu'ing  the  course 
of  an  abdominal  ojDeration,  a  lateral  woimd  half  an  inch  in  length 


Lancet,  1916,  Oct.  14,  p.  G79. 


DISTRIBUTION    AND    ANATOMICAL    CHARACTERS    2.3 

was  discovered  in  the  portal  vein  from  which  blood  was  pushing 
freely.  Two  artery  forceps  were  clamped  on  the  side  of  the  vein  in  a 
longitudinal  direction,  and  the  haemorrhage  Avas  controlled.  The  forceps 
were  left  in  position  until  the  third  day,  when  they  were  removed. 


Fig.   12. — Injured   Popliteal  Abteby 

AND    Vein,   followed    by    Gangbene 

OF  THE  Leg. 

The  vein  has  suffered  complete 
severance  as  a  result  of  the  passage  of 
the  bullet.  The  ragged,  frayed  ends  of 
the  vein  are  well  shown.  The  amount 
of  separation  of  the  ends  is  less  than 
the  average  distance,  a  fact  readily  ex- 
plained by  the  firm  nature  of  the  con- 
nection normal  to  this  particular  artery 
and  vein.  The  lower  end  of  the  vein  is 
still  occupied  by  a  thrombus. 

The  artery,  which  has  suffered  a 
severe  contusion,  presents  a  fusiform  en- 
largement occupied  by  a  thrombus  opjao- 
site  the  gap  between  the  ends  of  the 
severed  vein.  Both  above  and  below  the 
thrombosed  spot  the  calibre  of  the  vessel 
is  notably  diminished,  a  condition  usually 
seen  when  the  normal  arterial  circulation 
is  arrested  either  by  a  thrombus  or  a 
large  wound  involving  the  lumen.  Under 
the  care  of  Capt.  V/.  G.  Mumford. 


No  fm'ther  haemorrhage  took  place  from  the  vein,  but  on  the  eighth 
day  the  patient  had  an  attack  of  severe  hypogastric  pain,  vomited 
twice,  passed  bloody  urine,  and  died.  The  cause  of  death  was 
secondary  haemorrhage  from  an  injury  to  the  right  renal  artery.     At 


24        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

the  autopsy,  tlic  lunuMi  of  the  portal  vein  -was  found  to  l)e  ])atent,  and 
the  position-  of  the  wound  occupied  by  a  sound  scar.  Reference  will 
be  made  later  to  the  frequency  Avith  which  wounds  of  the  veins  of 
the  limbs  heal  spontaneoTisly,  especially  by  the  aid  of  adhesion  to 
neighbouring  structures. 

The  histological  details  met  with  in  a  wound  of  the  popliteal 
vein  twenty-four  hours  after  its  infliction  arc  portrayed  by  Captain 
Bashford  in  Fig.  14.  It  will  be  noted  that  verj^  little  injm-y  has 
been  suffered  by  the  wall  of  the  vein  in  the  neighbom-hood  of  the 
Avound.      The   endothelial  lining  of  the  vein  has  been  shed,  and  its 


Fig.   13. — Recent  perforation  of  common  iliac  vein.      Capf.  Adrian  Stokes. 

place  taken  by  a  layer  of  fibrin  deposited  on  the  inner  surface  of 
the  internal  elastic  lamina.  x-Vt  one  spot  at  the  lower  side  of  the 
section,  separation  of  the  muscularis  from  the  intirna  has  taken  place, 
and  opposite  to  this  the  internal  elastic  lamina  has  lost  its  natural 
curves,  while  beneath  it  some  fibrin  and  red  blood-corpuscles  have 
been  deposited.  This  specimen  is  from  a  comparatively  slight  injury, 
but  serves  well  to  illustrate  the  characters  which  ha^-e  been  described 
above. 


PROCESS  OF   REPAIR  OF  THE  INJURED  VESSELS. 

There  is  no  evidence  to  lead  to  the  opinion  that  any  variation 
from  the  normal  process  is  noticeable  in  the  method  of  repair  of 
vessels,  either  contused,  or  wounded  by  gunshot.  The  same  sequence 
of  prompt  contraction,  retraction  of  the  inner  coats,  and  jirovisional 
thrombosis  followed  by  endothelial  proliferation  at  the  injiu'ed  spot, 
and  final  organization  of  scar  tissue,  is  observed.  Any  special 
features  lie  in  the  severity  of  the  primary  injury  to  the  tissues,  the 
frequent  irregularity  of  the  process  as  far  as  symmetry  is  concerned, 
and  the  length  of  the  segment  of  the  vessel  which  the  subsequent 
cicatrization  may  inqDlicate. 


DISTRIBUTION    AND    ANATOMICAL    CHAHACTFAiS    25 

When  the  vessel  has  suffered  conipletc  division,  the  cnstoniary 
contraction  of  the  terminal  segment  of  the  free  extremity,  retraction 
of  the  mnscularis  and  intima  within  the  confines  of  the  adventitia, 
the  formation  of  a  provisional  thrombus  within  the  lumen,  and  some- 
times the  capping  of  the  free  extremity  by  a  convex  blood-clot,  are 
observed.     The  process  is  in  fact  identical  with   that  which  follows 


Fig.  14. — Section  of  recently  wounded  popliteal  vein.  All  the  coats  of  the  vessel 
are  divided  at  one  spot  on  the  right.  There  is  little  damage  to  the  wall  of  the  vessel 
around  the  opening.  Tlie  endothelium  is  shed,  and  a  layer  of  fibrin  and  blood  cover 
the  internal  elastic  lamina.  At  the  lower  part  of  the  figure  the  media  is  seen  to  be 
separated  from  the  intima.  Opposite  this  spot  the  elastic  lamina  is  stretched 
and  its  normal  ciirves  are  obliterated,  and  a  deposit  of  fibrin  and  red  blood-corpuscles 
separates  the  coats  of  the  vessel ;  this  is  shown  more  highly  magnified  in  B. 
Specimen  by  Capt.  Bashford. 

the  division  of  any  healthy  artery  by  a  blunt  instrument,  and  can 
perhaps  properly  be  compared  to  that  which  follows  surgical  torsion 
of  a  vessel. 

The  conditions  are  less  satisfactory  when  the  wound  is  a  lateral 
one  and  haemorrhage  continues,  either  externally,  or  into  the  surroimd- 
ing    tissues.     It   is    imder   these    circumstances    that   the   process    of 


2G        GUXSffOT    TX JURIES    TO    THE    BLOOD-VESSELS 

spontaneous  healing  does  possess  special  icaturcs  rarely  met  -with  in 
injuries  prodiiced  by  other  forms  of  violence.  If  the  openino;-  be  of 
the  nature  of  a  minute  puncture  caused  by  a  tiny  fragment  of  metal, 
or  of  the  limited  extent  produced  by  a  bullet  oi'  small  calibre,  there  is 
no  doubt  that  it  may  heal  spontaneously  by  the  normal  process.  I 
think  the  first  instance  of  spontaneous  healing  of  perforations  caused 
by  a  bullet  to  an  artejy  of  the  magnitude  of  the  abdominal  aorta, 
was  observed  by  Brentano*  during  the  Russo-Japanese  War.  In  this 
case  the  bullet  traversed  the  aoi-ta  just  above  the  origin  of  the  renal 
vessels,  and  then  passed  through  the  liver.  The  patient  died  on  the 
seventieth  day  from  the  results  of  a  subphrenic  abscess  Avhich 
developed  in  connection  with  the  wound  of  the  liver.  At  the  auto^Dsy 
the  cicatrized  entry  wound  was  visible  on  the  external  aspect  of  the 
vessel,  presenting  an  appearance  like  the  proximal  stiuiip  of  a  small 
branch  which  had  been  cut  off.  The  scar  of  the  exit  wound  was 
slit-like  in  character.  The  surface  of  the  vessel  was  coated  with  a 
layer  of  plastic  lymph,  quite  separate  from  the  suppurating  blood- 
clot  which  lay  around.  "When  the  vessel  was  opened,  at  first  glance 
the  healed  Avounds  were  hardly  visible  on  the  inner  surface,  and  both 
were  firmly  closed.  Since  the  period  of  that  observation,  closiu'C  and 
consolidation  of  perforations  has  been  observed  with  some  degree  of 
frequency  during  the  performance  of  operations,  particidarly  for  the 
cure  of  arterio-venous  aneurysms.  A  still  more  striking  example  of 
a  wound  of  the  abdominal  aorta  will  be  found  on  page  119. 

A  second  classical  case,  that  of  Majors  Johnston  and  I'reyer, 
may  be  mentioned.  A  patient  who  had  received  an  antero-posterior 
perforating  wound  of  the  thigh  implicating  the  femoral  vessels,  died 
fifteen  days  later  from  enteric  fever.  At  the  autopsy  the  wound  of 
entry  into  the  artery  was  closed  by  a  small  firm  clot  embedded  in 
the  sartorius  muscle,  the  small  circular  exit  wound  was  attached  to 
the  corresponding  opening  in  the  underlying  vein,  while  the  woinid  of 
exit  in  the  posterior  wall  of  the  vein  was  'nearly  cicatrized.'  This 
case  is  quoted  as  illustrating  an  early  stage  of  a  course  of  events 
often  met  with,  in  which  both  the  apertures  on  the  non-contiguous 
aspects  of  the  vessels  close  spontaneously,  while  those  from  which 
blood  can  pass  readily  from  one  vessel  to  the  other  remain 
patent.  This  method  of  spontaneous  control  of  ha-morrhage  or 
extravasation  has  now  become  a  matter  of  common  experience,  and 
it  will  be  referred  to  again  under  the  heading  of  aneiu-j^smal  varix. 
It  is  mentioned  here,  as  it  may  be  but  a  step  in  the  complete 
spontaneous    cure    of    an    arterio-venous     injury,    since    the    orifice 


Ueber  Gefasss^luissc,"  Archiv.  fur  kliiuschc  Cfiirurgie,  1906,  Bd.  80,  s.  304.. 


DISTRIBUTION    AND    ANATOMICAL    CHARACTERS 


connecting  the  lumen  of  the  artery  and  vein  may  occasionally  cod- 
tract  and  eventually  close. 

Spontaneous  healing  of  vascular  wounds  may  be  aided  by  the 
lateral  adhesion  of  other  structures  than  satellite  vessels — thus,  to 
muscles  or  nerves  which  take  a  parallel  course.  The  part  which 
may  be  taken  by  large  nerve  trunks  is  most  strikingly  illustrated 
in  the  case  of  the  axillary  artery,  where  the  conditions  are  more 
favourable  than  in  any  other  region  of 
the  body.  It  has  also  been  met  with 
not  infrequently  in  injuries  to  the 
brachial  artery. 

Fig.  15  depicts  the  ultimate  con- 
dition of  an  axillary  artery  in  which 
spontaneous  healing  has  been  effected. 
A  considerable  extent  of  the  wall  of  the 
artery  was  implicated,  principally  upon 
one  aspect.  It  is  seen  in  the  drawing 
that  the  muscular  coat  of  one  side  of 
the  vessel  is  practicall}^  normal  ;  on  the 
other  side  it  is  absent  for  a  consider- 
able stretch,  its  place  being  taken  by 
cicatricial  tissue.  The  remaining  mus- 
cle, where  it  lies  alongside  the  organized 
thrombus,  is  very  highly  vascidarized. 
A  striking  feature  in  this  section  is  the 
great  amount  of  sub-endothelial  thick- 
ening seen  opposite  the  site  of  maximal 
injury,  the  new  tissue  extending  right 
across  the  lumen  of  the  artery.  The 
organized  permanent  thrombus  contains 
a  large  number  of  blood-vessels,  suggest- 
ing a  very  early  stage  of  possible 
'  canalization.' 

During  the  South  African  War  a 
curious  instance  of  the  closure  of  an 
opening  in  the  brachial    artery  by  the 

insertion  of  a  loop  of  the  musculospiral  ner^e  was  recorded  by  Sir 
William  Stokes.  This  observation  is  interesting  in  relation  to  the 
question  of  temporary  or  permanent  closure  of  the  wound  in  the 
vessel  by  foreign  bodies  of  other  nature.  Temporary  restraint  of 
hamorrhage  from  wounds  of  large  vessels  by  persisting  firm  impact 
of  bullets  or  other  fragments  of  metal  is  a  familiar  condition,  as  also 
the  less  agreeable  experience  of  furious  haemorrhage  from  large  vessels 
such  as  those  of  the  neck  or  the  thieh,  followino-  the  remoAal  of  a 


Fig.  15. — Spontaneous  healing 
of  axillary  artery,  and  occlusion 
of  lumen.  Specimen  prepared  by 
Capt.  Greenjield. 


28        arXSIIOT    IXJ TRIES    TO    THE    BLOOD-VESSELS 

retained  foreign  body.  Fig.  7,  already  referred  to,  deiuoiistrates  the 
possibility  of  permanent  control  being  established  by  similar  means. 
A  striking  instance  of  temporary  control  of  lia^ntorrbage  from  a 
ANomided  popliteal  artery  is  fiu-nished  by  the  skiagram.  Fig.  16. 

Many  cases  have  been  recorded  ^vhich  ilhistrnte  the  capacitj^  of 


Fig.  10. — Skiagram  showing  the  Bones  of  the  Thigh  and  Leg  opposite 
THE  Popliteal  Space. 

An  impacted  bullet  is  seen  lying  transversely  in  the  popliteal  space.  The  point  of 
the  bullet,  after  traversing  the  popliteal  vein,  is  lodged  in  the  popliteal  artery  without 
penetrating  the  anterior  wall.  Removal  of  the  bullet  some  days  after  its  entrance 
was  followed  by  free  hemorrhage,  necessitating  ligature  of  both  vessels.  Under  the 
care  of  Major  Stojiey  Archer. 


Avounds  of  the  large  veins  to  cicatrize  spontaneously,  even  when  the 
point  of  entry  has  been  the  heart.  One  case  of  this  kind,  under 
the  care  of  Captain  Gregory,  which  came  under  my  own  observation, 
may  be  mentioned.  In  this  instance  a  skiagram  taken  in  the  suiDine 
position  showed  a  shrapnel  ball  in  the  lower  part  of  the  chest.  A 
second  skiagram  taken  in  the  erect  position  shoM'ed  the  shrapnel  ball 


DISTRIBUTION    AND    ANATOMICAL    CHARACTERS    29 

at  the  brim  of  the  pelvis,  The  ball  was  eventually  removed  from 
the  external  iliac  vein.  The  patient  died  later,  and  little  trace  of  the 
point  of  entry  of  the  missile  was  found  ;  it  was  decided  that  it  had 
descended  from  the  right  auricle.  It  had  seemed  possible  that  the 
ball  might  have  entered  the  vena  cava  from  the  hepatic  vein,  as  there 
was  a  large  track  in  the  liver,  bnt  examination  of  the  hepatic  vein 
afforded  no  definite  evidence  that  a  wound  had  existed.* 

It  may  be  added  that  a  remote  cure  of  an  arterial  wound  may 
be  efiected  by  solidification  of  a  traumatic  aneurysm.  Many  cases 
have  been  observed  in  which  this  sequence  of  events  occurred,  most 
frequently  in  the  case  of  the  loAver  end  of  the  femoral  or  of  the 
popliteal  artery. 

Fig.  44,  p.  170,  affords  a  remarkable  bond  of  union  formied  between 
the  ends  of  a  divided  carotid  artery,  A  solid  column  of  yomig  connec- 
tive tissue,  sinuilating  a  completely  thrombosed  artery  retaining  its 
normal  calibre,  connects  the  two  parts  of  the  vessel.  This  tissue  has 
been  laid  down  in  the  cavity  occupied  by  a  Tuflier's  tube  which  was 
retained  in  the  neck  for  four  days.  The  tube  was  removed  four 
Aveeks  prior  to  death  ;  had  the  patient  survived,  no  doubt  progressive 
cicatrization  would  have  reduced  the  column  to  the  condition  of  a 
narrow  connecting  cord. 


*  Capt.  Gregory,  British  Medical  Journal,  1917,  vol.  1,  p.  482. 


30 


CHAPTER    III. 

SYMPTOMS    AND    SIGNS 

OF    GUNSHOT    WOUNDS   OF  THE    BLOODVESSELS, 

AND    THE    TREATMENT    OF    HEMORRHAGE. 

The  evidences  of  a  gunshot  injury  to  the  blood-\esseIs  are  general 
and  local :  in  some  cases  the  general  symptoms  may  be  absent  and 
the  local  signs  so  trivial  as  to  create  the  impression  that  injury  to 
a  vessel  of  any  importance  is  improljable.  In  the  latter  case  the 
diagnosis  may  only  be  formed  as  a  result  of  the  development  of 
subsequent  manifestations,  such  as  lowering  of  the  vitalitj^  or  even 
gangrene  of  the  parts  supplied,  or  one  of  the  forms  of  traumatic 
aneurysm.  It  will  be  convenient  in  this  place  to  deal  with  the  general 
symptoms  and  initial  local  signs,  reserving  the  consideration  of  the 
consequences  for  Chapters  IV  and  V. 

It  is  unnecessary  to  deal  at  any  length  with  the  general  sym- 
ptoms due  to  the  loss  of  blood.  It  suffices  to  say  that  these 
are  evidences  of  a  pure  acute  anaemia,  often  to  a  certain  extent, 
influenced  by  the  phenomena  of  wound  shock — thus,  initial  psychic 
syncope,  pallor  and  anxiety  of  countenance,  bodily  ■weakness,  increase 
in  rapidity  and  compressibility  of  the  pulse,  combined  with  loss  of 
vohmie,  increased  rapidity  and  diniinished  dej)th  in  the  resj^iratory 
niovements,  vertigo,  roaring  noises  in  the  ears,  and  thirst,  often 
extreme.  In  cases  of  the  gravest  nature  all  these  symptoms  tend  to 
augment,  pallor  becomes  extreme,  restlessness  develops,  the  pulse 
becomes  progressively  weaker  until  it  flutters  out,  sweating  occurs, 
the  bodily  temperature  falls,  the  pupils  dilate,  and  the  patient  becomes 
sleepy  or  imconscious.  Occasional  deep  gasps  of  'air  hiuiger'  inter- 
rupt the  slowly  failing  respiration,  restlessness  and  perhaps  nmscular 
twitchings  increase,  and  death  may  be  preceded  by  relaxation  of  the 
sphincters. 

The  physical  signs  denoting  injmy  to  the  large  blood-vessels  may 
be  shortly  sunmiarized  as  follows  : — 

1.  External  ha:mor]-hage. 

2.  Internal  hcTmorrhage,  the  extra va sated  blood  collecting  within 
the  tissues  of  the  body.  This  may  give  rise  to  a  local  swelling, 
exaggerated  by  oedema  from  jDressure  on  the  veins  which  may  involve 
an  entire  limb.  The  condition  may  or  may  not  be  acconi|>anied  l^y 
superficial  ecchymosis. 


SYMPTOMS    AND   SIGNS  31 

3.  Evidence  of  interference  with  the  peripheral  circulation, 
indicated  by  diniimition  in  strength  or  actual  abolition  of  the  distal 
pulse,  and  a  fall  in  the  distal  blood-pressure. 

4.  The  development  of  a  systolic  bruit  over  the  wounded  spot 
in  the  artery,  or  the  development  of  a  continuous  venous  roar  with 
systolic  exacerbations,  when  both  artery  and  vein  are  implicated  and 
communicate  with  each  other.  These  bruits,  especially  when  the 
lesion  is  situated  in  the  lower  extremity,  may  be  in  some  cases  audible 
in  the  precordial  area. 

5.  Signs  of  disordered  nervous  function,  even  when  no  direct 
injury  has  been  sustained  by  the  peripheral  nerve  trunks. 

6.  Signs  of  lowered  vitality  or  of  gangrene  in  the  area  supplied 
by  the  injured  vessel. 

7.  The  subsequent  development  of  an  arterial  hai'matoma,  a 
traumatic  false  aneurysm,  or  an  arterio- venous  conmiunication. 

LOCAL    TREATMENT  OF  PRIMARY   H^flMORRHAGE. 

It  will  be  convenient  to  proceed  first  to  the  general  question  of 
haemorrhage — primary,  recurrent,  or  secondary — and  its  treatment. 

It  iTiay  be  premised  that  death  from  primary  haemorrhage 
accounts  for  a  very  large  proportion  of  the  fatal  casualties  of  battle, 
although  the  circumstances  under  which  the  deaths  take  place  pre- 
clude the  collection  of  accurate  statistics  upon  this  important  point. 
The  remarkable  feature  of  primary  haemorrhage  following  gunshot 
injuries  lies  in  the  experience  that  so  large  a  number  of  wounded 
men  escape  death  when  the  vascular  lesions  present  would  have  seemed 
to  render  a  fatal  issue  inevitable. 

The  most  striking  instances  of  escape  from  the  consequences  of 
wounded  arteries  are  seen  in  the  case  of  large  lacerated  wounds  in 
which  the  continuity  of  large  trunks  has  been  completely  interrupted  ; 
but  in  these — as  has  been  already  shown — the  nature  and  extent  of 
the  violence  exerted  on  the  walls  of  the  vessel  are  such  as  especially 
to  favour  spontaneoiis  control  of  the  bleeding.  The  type  of  injury, 
in  fact,  resembles  in  a  close  degree  that  seen  when  a  limb  is  totally 
avulsed,  in  accidents  of  which  category  the  escape  from  the  conse- 
quences of  a  ruptured  artery  is  also  a  classical  observation. 

In  the  second  favourable  form  of  gunshot  wound  as  far  as  escape 
from  the  dangers  of  primary  haemorrhage  is  concerned — the  narrow 
traversing  track — new  factors  beyond  the  contused  nature  of  the 
arterial  wound  are  introduced.  These  consist  first  in  the  shifting  in 
relative  position  of  the  various  planes  of  the  structiu-es  of  the  body 
traversed,  and  consequent  interruption  of  direct  continuity  in  the 
patency  of  the  track,  due  to  assumption  of  an  altered  position  of  the 


;32        GUNSHOT    JXJllUES    TO    THE    BLOOD-VESSELS 

part  of  the  body  imj/licatcd  snbsrciucntly  to  rccc))tion  of  the  ^vo^^nd. 
Chaiice  of  position,  an  almost  invariable  sequence  to  the  blow  of  the 
missile,  develops  irregularity  and  an  increase  of  intricacy  in  the  track, 
and  thus  obstructs  the  passage  of  blood  to  the  sm'face.  Further,  if 
haemorrhage  continues  into  the  tissues,  pressure  consequent  upon 
this  irregularity  of  the  track  is  exerted  upon  the  Avoiuided  s])ot  in 
the  vessel,  and  a  second  ha'mostatic  influence  is  brought  into  play. 

Whenever  haemorrhage  persists  and  gives  rise  to  danger,  either 
from  direct  loss  of  blood,  or  from,  increasing  pressure  due  to  collection 
of  blood  within  the  tissues  of  the  ^vounded  part,  the  classical  procediire 
of  ligatiu'e  of  the  vessel  at  the  wounded  spot  is  to  be  followed  should 
the  circumstances  jDcrmit.  If  it  be  necessary  to  maintain  temporary 
control,  modification  of  the  same  principle  should  be  made  use  of, 
and  the  pressure  exerted  directly  over  the  wound  in  the  vessel. 

If  a  vessel  be  so  situated  as  to  be  capable  of  being  grasped  and 
controlled  by  an  artery  forceps,  but  the  ap]:)lication  of  a  ligature  is 
impracticable,  the  artery  forceps  should  be  left  in  position  and  the 
wound  lightly  filled  ^vith  gauze.  The  tissues  should  not  be  too  firmly 
grasped,  and  then  the  forceps  may  remain  in  position  for  several  days 
before  removal,  or  be  left  until  the  clamped  end  of  the  vessel  separates 
spontaneously. 

The  application  of  a  proximal  ligature  should  be  reserved  for 
very  exceptional  cases  of  urgency  ;  and  in  every  instance,  if  the  main 
trunk  musi  be  occluded,  the  ligature  nuist  be  applied  in  as  close 
proximity  to  the  wound  as  possible.  The  seat  of  election  is  theoretic- 
ally and  practically  the  most  unsuitable  spot  to  choose,  since  it  does 
not  eliminate  the  collateral  supply  of  blood  to  the  parts  between  the 
point  of  ligature  and  the  original  wound,  although  by  the  greatly 
decreased  supply  which  it  leaves  for  the  wounded  aiea  it  seriously 
diminishes  the  protective  power  of  the  tissues  against  infection. 

When  the  soiu'ce  of  the  ha?morrhage  is  from  small  vessels  not 
readily  reached,  or  wdien  the  bleeding  is  actually  parenchymatous  in 
character,  the  wound  may  be  plugged  after  proper  mechanical 
cleansing.  A  method  somewhat  extensively  employed,  especially  by 
French  surgeons,  consists  in  ]iro visional  suture  of  the  wound  over 
the  haemostatic  plug.  It  may  be  pointed  out  that  if  the  primar}'^ 
cleansing  and  preparation  of  the  wound  has  been  eflicieiit,  neither  of 
these  measvires  prevents  secondary  closure  of  the  wound,  at  a  date 
varying  from  three  or  four  to  ten  days,  provided  the  conditions  are 
favourable  as  to  the  size  of  the  wound  and  the  means  of  caring  for  it. 

The  last  resource  for  temporary  control  of  bleeding,  the  a])j)lica- 
tion  of  a  tourniquet,  is  a  vexed  question  not  easy  of  solution.  Every 
siu-geon  v/ould  gladly  eliminate  this  dangerous  and  chm\sy  procedure 
from  his  ]:)ractice.     ^'et  circiunstances  do  occiu'  when  the  use  of  the 


SYMPTOMS    AND    SIGNS  33 

tourniquet  is  unavoidable,  srich  as  the  absence  of  skilled  assistance, 
want  of  time,  the  position  in  which  the  patient  may  find  himself 
situated,  or  the  nature  of  the  surroundings.  It  can  only  be  said, 
therefore,  if  the  tourniquet  be  the  sole  available  means  of  temporarily 
arresting  the  haemorrhage,  that  every  precaution  must  be  taken  to 
make  sure  that  the  band  is  released  at  the  earliest  possible  mom.ent  : 
further,  that  no  patient  be  subjected  to  transport  without  being 
specially  marked,  so  that  the  presence  of  the  tourniquet  be  not  over- 
looked. Even  when  the  latter  precaution  is  observed,  the  evil  effects 
of  too  tight  or  too  prolonged  application  of  the  tourniquet  are 
unhappily  far  from  unfamiliar.  Naturall}^  the  most  frequent  instances 
of  the  evil  effect  of  the  tourniquet  are  seen  in  patients  who  have 
either  constricted  their  own  limbs,  or  in  whom  the  tourniquet  has 
been  applied  by  a  fellow-  soldier. 

When  the  haemorrhage  is  internal,  and  no  lu-gent  signs  of  loss  of 
blood  or  of  danger  from  pressure  are  present,  we  are  faced  with  a 
question  which  has  given  rise  to  much  discussion.  We  know  that  in 
a  large  proportion  of  such  cases  the  bleeding  will  undergo  spontaneous 
arrest,  either  as  a  result  of  natural  processes  effected  at  the  wounded 
spot  in  the  vessel  itself,  or  by  the  pressure  of  the  blood  already 
extravasated  into  the  tissues  and  unable  to  escape  to  the  surface  of 
the  body  by  the  original  track  produced  by  the  missile. 

It  has  been  argued  that  certain  knowledge  of  the  presence  of  a 
wound  in  a  large  arteiy  should  be  at  once  followed  by  resort  to  the 
normal  procedure,  that  is  to  say,  suture  or  ligature  of  the  vessel  at 
the  bleeding  point.  This  view  is  supported  by  the  self-evident  fact, 
that  if  this  course  be  taken  and  prove  successful,  the  following  risks 
are  at  once  eliminated,  and  a  prolonged  course  of  subsequent  treatment 
is  avoided  :  recurrent  or  secondar}^  haemorrhage  ;  gangrene  dependent 
on  pressure  exerted  by  extravasated  blood-clot  upon  both  the  main 
vessel  and  its  neighbouring  collateral  branches  ;  and  the  remote 
formation  of  any  of  the  various  forms  of  traumatic  aneurysm.  In 
fact,  by  adopting  the  proper  method  the  surgeon  not  only  relieves  the 
patient  from  the  immediate  dangers  of  the  condition,  but  also  removes 
from  the  future  all  risks  of  a  sequence  of  serious  complications,  and 
enormously  reduces  the  duration  of  the  course  of  treatment  required. 

On  the  other  hand,  difficulties  have  been  raised  to  the  adoption 
of  the  ideal  method  of  treatment  proper  to  this  class  of  injury  at 
advanced  stations  on  the  line.  It  has  been  asserted  that  most  recent 
gunshot  wounds  are  already  infected,  and  further,  that  an  oj)eration 
incision  made  at  an  advanced  post  is  practically  certain  to  become 
so.  Hence  it  has  been  argued  that  suture  is  an  impracticable  and 
ligature  a  dangerous  procedure.  Fiu-ther,  it  has  been  said  that  if  an 
interval  be  allowed  to  elapse  between  the  receipt  of  the  injurv  and 

3 


31       GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

the  permanent  occlusion  of  the  main  Aessel,  vahiable  time  is  gained 
in  which  compensatory  enlargement  of  the  collateral  circulation  makes 
progi'ess  ;  thus,  the  clangers  attendant  on  sudden  local  anaemia  are 
reduced,  and  gangrene  is  less  likely  to  supervene.  I'he  last  serious 
objection  to  immediate  operation  is  one  v\'hich  obtains  in  all  cases  of 
whatever  natiu-e,  the  danger  of  subjecting  to  any  operation  whatever 
a  patient  who  has  recently  lost  a  large  quantity  of  blood,  especially 
if  a  general  ana-sthetic  be  necessary. 

During  the  present  war  some  general  changes  of  opinion  have 
taken  place,  but  they  are  rather  in  the  nature  of  compromise  than 
in  the  acquisition  of  experience  which  fully  justifies  any  attempt  to 
lay  down  invariable  rules  for  treatment. 

With  regard  to  immediate  radical  treatment,  it  has  been  proved 
that,  in  the  absence  of  bleeding,  little  harm  can  result  from,  the  delay 
attendant  ujjon  the  removal  of  'womided  men  to  the  line  of  special 
units  equipped  for  operative  woik,  or  to  the  casualty  clearing  station 
which,  imder  the  conditions  of  the  Avarfare  of  the  first  three  years, 
assumed  the  functions  of  the  stationary  hospital  on  the  lines  of 
communication. 

It  has  also  been  pro\'ed  that  within  a  period  of  six  to  t^^'elve 
hours,  wounds  properly  cleansed  by  mechanical  methods  coming  far 
short  of  complete  excision  of  the  walls  of  the  cavity,  may  be  ]:)romi)tly 
closed  and  may  heal  permanently  by  ]:)rimary  union,  provided  that 
a  proper  interval  of  rest  can  be  assured  ]jrior  to  further  transport  of 
the  patient. 

Thus  the  primary  cause  of  failure  in  the  earlier  periods  of  the 
campaign  has  been  eliminated,  and- — given  conditions  and  surroundings 
such  as  obtained  during  the  winter  of  1917-1 S,  when  the  casualty 
clearing  stations  were  able  to  carry  on  their  work  practically 
unmolested — the  treatment  of  wounded  arteries  falls  into  line  with 
that  of  other  serious  wounds,  such  as  those  of  joints  or  even  severe 
compound  fractures  of  the  bones  of  the  limbs.  Tf  such  conditions 
can  be  assured,  then  the  cardinal  rule  of  surgery  that  a  wounded 
vessel  shall  be  secured  at  the  earliest  possible  moment  can  be  followed, 
and  the  advantages  already  enumerated  will  be  gained. 

During  active  military  operations,  however,  combined  -with  the 
necessity  of  shifting  the  situation  of  the  operating  centres  and  the 
rapid  evacuation  of  woimded  men,  times  Avill  always  occur  when 
conditions  unfavourable  to  the  performance  of  operations  will  obtain. 
In  this  case  the  following  rules  would  seem  appropriate  : — 

1.  Bleeding  vessels  in  an  open  woimd  should  always  be  secured 
at  the  earliest  possible  moment. 

2.  When  injiu-ed  vessels,  and  cs]K'cially  those  of  lai-ge  calibre,  are 
visible  in  open  wounds,  they  must  be  ligatured  whether  bleeding  is 
taking  place  or  not. 


SYMPTOMS    AND    SIGNS  35 

3.  When  a  larae  vessel  is  exposed  in  an  open  wound  and  has 
obviously  suffered  contusion  and  is  thrombosed,  the  vessel  should  be 
ligatured  above  and  below  the  thrombosed  segment,  and  the  latter 
excised.  This  procedure  obviates  the  subsequent  danger  of  secondary 
haemorrhage,  v.'hich  is  incalculable  from  external  inspection  of  the 
vessel  alone,  as  has  been  seen  from  the  section  devoted  to  contusion 
of  the  arteries. 

4.  When  evidence  exists  that  a  large  vessel  has  been  woimded  in 
the  course  of  a  track  traversing  the  body  or  limbs,  imless  the  condi- 
tions are  favourable,  it  is  not  advisable  to  interfere  primarily  if  no 
signs  of  progressing  haimorrhage  are  forthcoming,  nor  indications  that 
the  vitality  of  a  distal  portion  of  the  limb  is  becoming  endangered. 
In  all  such  cases,  although  an  arterial  hematoma  and  subsequently 
a  false  traumatic  aneurysm  may  result,  yet  the  later  treatment  of 
either  of  these  conditions  under  favourable  circumstances  for  opera- 
tion is  to  be  preferred  to  the  risks  attendant  on  a  primary  operation. 

RECURRENT     AND     SECONDARY     HEMORRHAGE. 

Recurrent  Haemorrhage — The  occurrence  of  recurrent  bleeding 
in  a  large  number  of  those  patients  in  whom  it  had  ceased  spontane- 
ously under  the  influence  of  shock  and  rest,  either  Avhen  the  patients 
are  moved,  or  when  the  woimds  are  disturbed  for  the  pur2:)ose  of  being 
cleansed  and  dressed,  is  not  a  matter  to  cause  surprise.  The  treatment 
of  this  accident  differs  in  no  particular  from  that  of  primary  ha-mor- 
rhage,  and  needs  no  further  mention  here. 

Secondary  Haemorrhage,  either  from  the  systemic  or  visceral 
vessels,  is  vmhappily  still  a  frequent  sequence  to  those  gunshot  wounds 
which  it  has  been  impossible  to  preserve  from  the  sinister  influence  of 
infection.  The  experience  in  the  earlier  stages  of  the  present  war 
recalled  those  of  the  pre-Listerian  era,  and  even  under  the  increasingly 
favourable  conditions  of  more  recent  times  the  occurrence  of  this 
accident  has  been  deplorably  common. 

Beyond  the  all-important  factor  of  septic  infection,  others  enter 
into  the  category  of  causes  of  this  complication — thus,  the  nature 
of  the  primary  injury  which,  beyond  inflicting  a  number  of  perfor- 
ating wounds  in  vessels  scattered  widely  in  all  parts  of  a  very 
extensive  wound,  may  also  occasion  multiple  vascular  lesions  of 
great  severity,  but  not  actually  perforating  the  walls  of  the  vessel 
at  the  time.y^  The  first  circumstance,^ favours  the  escape  frotn  the 
attention  of  the  surgeon  who  is  called  upon  to  deal  with  the  case 
primarily,  of  individual  perforations  which  may  lie  more  or  less 
hidden  in  remote  extensions  of  the  wound,  and  may  also  perhaps  have 
'spontaneous!}'"  ceased   to  bleed.    _The  second   obtains  a    still   greater 


30        GUNSHOT    IXJVRIES    TO    THE    BT.OOD-VESSELS 

importance  iroiii  the  fact  that  sc])sis  is  not  an  inevitable  factor  in 
the  causation  of  secondary  ha-niorrhage,  but  the  injured  wall  of  the 
vessel  may  give  way  as  a  result  of  the  final  sej^aration  of  a  portion  of 
tissue  which  is  eompletelv  de\italized  althouah  temporarily  contimious 
with  the  still  livin<>'  tissi'.c.  If  septic  infection  docs  suj^ervene,  tissue 
much  less  seriously  injiu'cd  may  have  had  its  vitality  lowered  to  such 
a  degree  as  to  fall  an  easy  prey  to  the  ravages  of  micro-organisms. 

Certain  peculiarities  in  the  normal  anatomy  of  individual  vessels 
also  exercise  an  influenee  on  the  occTU'rcnce  of  secondary  hteniorrhage  : 
the  most  important  of  these  is  mechanical  fixation,  especially  to  the 
bones.  The  significance  of  this  factor  has  already  been  alluded  to 
in  relation  to  the  manner  in  Avhich  it  may  affect  the  possibility  of  the 
€scape  of  a  vessel,  or  acc!ount  for  the  relative  degrees  of  damage,  as 
evidenced  by  the  infliction  of  contusion,  non-23erforating  laceration, 
-actual  ]Derforation,  or  complete  division  respectively.  Anatomical 
fixation  has  a  further  action  in  preventing  the  normal  retraction  and 
contraction  consequent  upon  the  stimulus  of  injury  to  an  artery  ;  hence 
the  AA-ounded  vessel  may  be  retained  at  the  surface  of  a  woimd,  and 
perhaps  with  a  patent  orifice.  The  conditions,  indeed,  bear  a  strong 
resemblance  to  those  consequent  on  the  fixation  resulting  from  infil- 
tration and  inflammatory  induration  on  the  vessels  contained  in  the 
tissues.  A  few  of  the  arteries  influenced  by  such  anatomical  arrange- 
ments, and  from  which  secondary  hainiorrhage  frequently  takes 
place,  may  be  mentioned — thus,  the  circumflex  branches  of  the 
axillary  as  they  pass  around  the  neck  of  the  humerus,  the  several 
scapular  arteries  where  they  are  held  in  close  connection  with  the 
borders  of  the  bone,  the  gluteal  artery  as  it  emerges  from  the  pelvis, 
the  circumflex  branches  of  the  profunda  femoris  and  the  parent  trunk 
itself  as  it  dips  beneath  the  adductor  longus  (the  fixation  here  depend- 
ing on  relation  to  muscles  and  not  to  bone),  the  superficial  femoral 
as  it  leaves  Hunter's  canal,  the  articular  branches  of  the  popliteal  as 
they  lie  on  the  surface  of  the  lower  end  of  the  femur,  and  the  anterior 
tibial  artery  as  it  pierces  the  interosseous  membrane  and  where  it  is 
attached  to  the  anterior  surface  of  that  membrane. 

Attacks  of  secondary  haemorrhage  are  often  heralded  by  a  rise 
in  the  bodily  temperature,  and  an  increase  in  rapidity  and  irritability 
in  character  of  the  pulse.  This  ma}''  be  regarded  as  an  indication 
that  secondary  hirmorrhage  often  follows  an  increase  in  the  degree 
of  infection.  The  immediate  onset  may  be  accompanied  by  j^ain, 
but  in  many  instances  the  bleeding,  although  fiu'ious,  may  come  on 
insidiously  and  only  be  detected  by  the  patient  or  attendant  by  the 
discovery  of  blood  in  the  dressings  or  the  bed.  The  classical  sequence 
of  one  or  more  insignificant  haemorrhages  is.  however,  the  most 
common  course  of  events,  and  one  of  which  the  import  should  never 
be  discounted  or  disregarded. 


SYMPTOMS    AND   SIGNS  37 

When  the  secondary  ha^'morrhage  is  of  the  internal  variety,  pain 
resulting  from  tension  and  separation  of  the  tissues  is  usually  the  first 
indication. 

Treatment  of  Secondary  Hcemorrhage. — -The  routine  ])roeedu]-e 
in  all  cases  of  secondary  haemorrhage  consists  in  the  application  of 
a  ligature  to  the  bleeding  point.  This  may  prove  a  matter  of  extreme 
difficulty,  either  by  reason  of  the  anatomical  position  of  the  vessels 
from  which  the  bleeding  proceeds,  or  the  unsatisfactory  state  of  the 
walls  of  the  vessels  themselves  and  of  the  surrounding  tissues. 

It  is  rare  indeed  that  proximal  ligature  of  the  main  trunk  supply- 
ing the  wounded  area  is  justifiable.  This'  operation  involves  the 
collateral  vessels  more  extensively,  is  much  more  dangerous  to  the 
future  vitality  of  the  tissues,  perhaps  to  a  limb  itself ;  and  in  a  very 
large  percentage  of  instances  is  but  a  temporarj^  expedient,  since 
recurrence  of  the  secondary  haemorrhage  is  a  common  event.  Only 
one  exception  to  this  general  statement  appears  to  be  justified  by 
practical  experience,  and  that  is  in  the  case  of  ligature  of  the  internal 
iliac  artery  or  its  posterior  division,  when  bleeding  is  taking  place 
from  one  of  the  vessels  of  the  buttock  close  to  the  point  at  which  it 
emerges  from  the  pelvis.  I  have  seen  a  number  of  patients  in  whom 
proximal  ligature  has  been  successful  in  these  circumstances,  but 
success  in  the  case  of  any  other  trunk  is  rare.  Even  in  the  ease  of 
the  internal  iliac,  gangrene  of  the  tissues  of  the  buttock  has  been 
observed  occasionally.  Proximal  ligature  of  the  main  artery  at  the 
seat  of  election  is  therefore  to  be  condemned,  and  may  only  be  resorted 
to  when  no  other  course  is  possible.  Further,  should  it  be  considered 
necessary  to  deal  with  a  main  trunk,  the  ligature  should  be  applied 
in  as  close  proximity  as  possible  to  the  actual  wounded  spot,  difficulties 
of  access  being  disregarded  as  far  as  possible.  The  latter  procedure  is 
jDerhaps  most  useful  when  haemorrhage  from  an  amputation  stump 
has  to  be  dealt  with.  It  has  here  the  advantages  of  rendering  unneces- 
sary free  handling  and  disturbance  of  flaps  which  may  have  in  great 
part  united,  and  of  avoiding  having  to  deal  with  a  softened  artery,  to 
tie  which  effectively  the  vascular  cleft  must  be  followed  up  to  an 
undesirable  extent ;  it  allows  a  comparatively  healthy  portion  of  the 
vessel  to  be  dealt  w^th  at  the  bottom  of  a  fresh  wound,  and  at  the 
same  time  does  not  encroach  unduly  upon  the  blood-supply  of  the 
flaps  by  collateral  vessels. 

As  a  general  rule,  shoifld  the  application  of  a  ligature  or  forci- 
pressure  prove  unsuccessful  or  impracticable,  the  w^ound  must  be 
plugged.  Plugging  may  prove  successful  even  when  large  arteries 
provide  the  source  of  the  bleeding  ;  it  is  frequently  so  when  smaller 
vessels  are  at  fault  in  the  wounds  of  patients  suffering  from  toxaemia 
or  septicaemia,  or  if  the  haemorrhage  is  of  the  parenchymatous  class. 


38        GUNSHOT    IXJllilKS    TO    THE    liLOOD-VESSELS 

If,  liowevcr.  this  practice  be  resorted  to,  the  surgeon  must  be  content 
to  risk  the  condition  of  the  Avound  as  far  as  dressing  is  concerned,  and 
allow  the  plug  to  remain  in  position  for  several  days,  or  a  Avcek  or 
more  if  necessary.  In  adopting  this  plan  it  must  be  kept  in  mind 
that  in  granulating  wounds,  an}''  blood  which  escapes  tends  for  the 
most  part  to  remain  in,  or  escaj^c  externally  from,  the  cavity,  and 
not  to  infiltrate  and  dissect  ujd  the  limb  as  it  may  do  in  a  recent  injury. 
Even  in  recent  wounds,  the  experience  of  the  salt  pack  as  recom- 
mended at  one  time  by  Colonel  Gray,  and  the  safety  Avith  which  woinids 
anointed  with  Mr.  Rutherford  Morison's  compound  of  l)isniiith. 
iodoform,  and  paraffin  may  remain  luidisturbcd,  su])]Dort  the  justifi- 
ability of  leaving  a  plug  in  position  for  prolonged  periods.  It  seems 
almost  unnecessarj'^  to  add,  that  in  introducing  ])lugs  which  are 
intended  to  rest  for  a  prolonged  period  in  a  Avound  from  which 
secondary  hcTmorrhage  is  occurring,  the  utmost  care  must  be  exercised 
that  every  extension  and  crevice  of  the  cavity  be  efficiently  filled  ; 
for  upon  this  precaution  the  success  or  failure  of  the  procedure  will 
ultimately  depend.  A  hastily  and  imperfectly  introduced  mass  of 
gauze  may  prove  worse  than  useless  for  the  2Durpose  intended. 

The  final  resort  in  secondary  haemorrhages  from  the  limbs  lies 
in  amputation. 

A  fcAv  words  may  be  added  as  to  the  general  treatment  of  patients 
who  have  suffered  from  severe  haemorrhage.  The  usual  precautions 
of  removal  of  tight  clothing,  the  arrangement  of  the  j^aticnt  with  the 
head  low,  the  insurance  of  complete  immobility  and  rest,  will  at  once 
follow  the  local  arrest  of  the  bleeding.  On  these  precautions  should 
follow  the  application  of  warm  coverings,  and  additional  heat  obtained 
by  the  apiDlication  of  warm  bottles,  or  if  circumstances  permit,  in 
bad  cases,  some  form  of  warm-air  bath. 

Even  in  secondary  ha-morrhages  the  internal  administration  of 
drugs  cannot  be  relied  upon  to  afford  any  useful  aid  ;  in  both  primary 
and  secondary  ha-morrhage  an  increase  in  the  total  vohmic  of  fluid 
in  the  vessels  is  the  main  object  to  be  striAT-n  after. 

The  Replacement  of  Blood.* — "NMiile  it  may  be  stated  that  blood 
is  the  best  fluid  Avith  which  to  replace  lost  blood,  yet  in  practice 
this  course  may  be  impossible  or  luinecessary.  With  a  moderate 
ha-morrhage  there  is  no  need  to  replace  the  lost  blood  artificialh^. 
If  the  bleeding  has  been  more  severe,  the  loss  can  be  made  good  by 
a  more  easily  obtainable  fluid,  i.e.,  Bayliss's  0  per  cent  gum-arabic 
solution.     A  still  more  se\T-re  hemorrhage  Avill  demand  blood. 


*  W.  M.  Bayliss,  F.R.S.,  JNIedical  Research  Committee's  Memorandimi, 
No.  1,  on  Intravenous  Injections  to  Beplacc  Blood;  Osavald  Roberts,  Med.  Res. 
Comm.  Mem.,  No.  4,  on  Blood  Transfusion. 


SYMPTOMS    AND   SIGNS  39 

A  precise  indication  as  to  when  blood  transfusion  is  imperative 
is  still  wanting,  and  much  to  be  desired.  Most  observers  are  agreed 
that  a  critical  point  has  been  reached  when  the  total  haLrnoolobin 
content  is  as  low  as  30  per  cent.  In  prinjary  hjcniorrhai'C  it  is  luifor- 
tunately  not  possible  to  calculate  the  haemoglobin  value  without  an 
elaborate  procedure  which  is  not  easily  carried  out.  Other  aid  must 
therefore  be  sought.  Clinical  signs  are  of  a  certain  value,  but  very 
often  it  is  hard  to  determine  from  a  patient's  appearance  how  much 
blood  has  been  actually  lost,  and  ocular  demonstration  of  the  amoiuit 
is  usually  wanting. 

In  these  circiuustances  the  blood-presstire  is  a  valuable  guide. 
A  systolic  pressure  determined  by  the  auscultatory  method,  which 
remains  below  80  mm.  of  mercury  for  hours,  is  an  indication  that 
help   is  required. 

The  question  to  be  settled  is  what  the  nature  of  this  aid  should 
be.  The  changes  that  take  place  after  a  haemorrhage  give  some  useful 
indications.  Directly  blood  is  lost,  fluids  begin  to  ]oass  into  the 
circulation  from  the  tissues.  The  resulting  dilution  of  the  remaining 
blood  continues  for  some  days  until  the  blood  volume  is  restored  or 
exceeded.  Further,  the  manufacture  of  haemoglobin  and  red  blood- 
cells  begins,  and  proceeds  until  the  normal  is  attained. 

The  first  want  therefore  is  fluid.  This  can  be  supplied  either  by 
the  mouth  or  by  the  rectum,  provided  that  the  patient  can  take  and 
retain  fluid  by  one  of  these  channels,  and  the  call  is  not  imperative. 
If  these  methods  be  ineffective,  impossible,  or  too  slow,  fluid  may  be 
introduced  directly  into  the  circulation.  The  best  artificial  fluid  for 
this  purpose  is  Bayliss's  6  per  cent  solution  of  gum  arable  in  normal 
saline.  If  introduction  of  this  fluid  fails  to  produce  the  required 
result  and  to  raise  the  blood-pressure,  recourse  must  be  had  to  trans- 
fusion of  blood. 

The  matter  may  be  shortly  simimed  up  as  follows  : — 

1.  Primary  Hcemorrhage.  —  In  sudden  and  abundant  haemor- 
rhage, immediate  transfusion  is  indicated. 

2.  In  less  severe  cases,  Bayliss's  gum-arabic  solution  should  be 
tried,  and  followed  by  transfusion  of  blood  if  no  permanent  effect  ha.s 
been  produced. 

3.  In  milder  eases,  an  attempt  to  restore  the  blood  volmne  may 
be  made  by  the  administration  of  large  amounts  of  fluid  by  mouth  or 
by  rectum.     If  necessary  these  attempts  may  be  follo'SAcd  by  2. 

Secondary  Hcemorrhage. — In  this  case  the  haemoglobin  content 
is  most  likely  already  depressed  to  the  critical  point.  Consequently, 
even  a  moderate  haemorrhage  Avill  reduce  it  to  a  point  inconq3atible 
with  an  efficient  natural  recover}^ ;  hence  immediate  transfusion  of 
blood  is  the  safest  course.     The  beneficial  effect  to  be  hoped  for  from 


40        GUXSIIOT    IXJilUES    TO    THE    BLOOD-VESSELS 

transfusion  is  greatly  lessoned  in  ])atients  the  subjects  of  general 
in.feetion. 

Signs  of  Interference  with  the  Distal  Circulation — Inspection 
of  the  part  affected  n\ay  reveal  pallor  when  the  artery  alone  is 
wounded,  or  congestion  and  cyanosis  when  both  ai-tery  and  vein  are 
affected.  The  part  may  also  be  cold  to  the  touch.  The  evidence 
furnished  by  examination,  of  the  pulse  to  the  distal  side  of  the  injury 
is  im]:)ortant  both  as  denoting  to  some  extent  the  gravity  of  the  local 
lesion,  and  also  as  indicating  the  sufficiency  of  the  collateral  supply 
to  the  part.  Many  factors,  however,  combine  to  render  it  no  more 
than  a  contributory  aid  ;  thus  interference  with  the  pulse  may  be  due 
to  temporary  pressure  exerted  by  a  fragment  of  bone,  a  displaced 
bone,  a  retained  foreign  body,  or  extravasated  blood.  Again,  it  may 
be  due  to  thrombosis,  or  the  pulse  may  be  impalpable  simply  as  a 
result  of  the  general  depression  of  the  blood -pressu.re  when  only  slight 
local  obstruction  exists.  These  factors  are  to  be  remembered  in 
deciding  upon  the  necessity  of  any  intervention,  and  especially  that 
of  amputation.  In  the  latter  case  absence  of  a  distal  pulse  cannot  be 
accorded  the  weight  in  forndng  a  decision  which  used  to  be  given  it, 
excejDt  when  gross  infection  of  the  wound  in  general  by  anaerobic 
organisms  is  suspected  or  known  to  exist.  As  a  sign  of  an  arterial 
wound  its  value  is  slight  compared  with  the  evidence  to  be  obtained 
by  the  use  of  auscultatory  methods. 

A  comparative  fall  in  the  distal  blood-pressure  of  the  part  is  a 
sign  of  some  constancy,  but  not  of  any  great  practical  utility  in  dealing 
with  the  early  stages  of  these  injuries.  It  gains  more  importance  in 
the  consideration  of  the  proper  treatment  to  be  adopted  in  aneurysms, 
and  will  be  dealt  with  when  this  subject  is  reached. 

EFFECTS      OF      WOUNDS      OF      THE     ARTERIES      ON      THE 
GENERAL      CIRCULATION. 

Wounds  of  the  large  blood-vessels  are  commonly  attended  by 
apparent  enlargement  and  excited  action  of  the  heart.  These  signs 
are  fairly  constant  in  the  early  stages  followdng  the  injuries,  biit  vary 
in  degree  and  mutual  relationship,  tending  to  subside  with  rest  in 
the  recumbent  position  and  W'ith  development  of  the  gradual  com- 
pensation which  follow^s  when  the  opening  in  the  arterial  wall  has 
remained  patent  for  some  time. 

In  a  large  proportion  of  cases  of  injury  to  the  larger  arteries  the 
apex  of  the  heart  will  be  found  in  the  nipple  line,  less  frequently 
outside  that  line  even  to  the  extent  of  one  to  two  inches,  and  some- 
times raised  above  the  normal  level.  The  pulse-rate  averages  from 
90  to   120.     The  degree   of    either    enlargement   or   excitement  may 


SYMPTOMS    AND    SIGNS  41 

vary  with  individual  idiosyncrasy  and  the  psychic  induciiccs  so 
common  in  gunshot  injuries,  and  both  are  more  marked  when  primary 
loss  of  blood  has  been  great  or  toxa-mia  is  a  factor.  Allowing  full 
weight  to  these  general  factors,  however,  no  doubt  can  exist  that 
a  simple  defect  in  the  arterial  wall,  in  communication  with  a  lateral 
chamber  in  which  the  blood  is  constantly  circulating,  demands 
increased  cardiac  effort  to  maintain  the  flow  of  blood.  This  effort 
must  be  the  greater,  since  the  circulation  of  the  blood  through  the 
cavity  does  not  receive  the  normal  aid  afforded  by  the  elastic  wall  of 
the  blood-vessel,  and  the  blood  contained  within  the  cavity  is  not 
controlled  by  the  proper  vasomotor  mechanism,  and  meanwhile  the 
imperfectly  supplied  distal  portions  of  the  body  call  for  their  normal 
supply. 

The  call  on  the  cardiac  muscle  is  probably  greatest  during  the 
period  in  which  a  simple  arterial  hsematoma — that  is,  a  pool  of  fluid 
blood  in  direct  continuity  with  the  arterial  blood-stream — is  still 
present.  Following  the  ordinary  physical  law,  this  large  collection  of 
blood  will  be  maintained  at  a  pressure  equal  to  that  of  the  general 
circulation,  and  the  force  for  this  extra  duty  must  be  furnished  by 
the  heart,  the  local  resistance  offered  being  merely  that  of  the 
surrounding  tissues  of  the  limb,  in  place  of  the  highly  regulated 
support  of  the  arterial  wall. 

When  an  arterio-venous  communication  has  been  established, 
the  obstruction  to  and  disturbance  of  the  circulation  are  still  more 
serious.  In  these  circumstances,  the  arterial  flow  diverted  from  its 
normal  course  is  driven  into  and  distvirbs  the  slower  reverse  current 
in  the  vein.  The  walls  of  the  vein,  as  a  result  of  the  increased  intra- 
vascular pressure  to  which  they  are  subjected,  stretch,  and  thus  a 
great  bay  is  formed  in  which  a  swirling  eddy  is  established.  In  this 
way  obstruction  is  offered  to  the  current  in  the  distal  segment  of 
the  vein,  while  a  varying  proportion  of  the  arterial  blood  destined 
to  the  supply  of  the  perijoheral  portion  of  the  body  jDasses  directly 
backward  to  the  heart. 

That  an  arterial  leak  acts  practically  as  an  actual  obstruction  to 
the  circulation  appears  obvious  from  the  immediate  fall  in  the  distal 
blood-pressure  which  takes  place.  This  fall  coincides  for  a  prolonged 
period  with  that  observed  when  the  main  artery  suppl3^ing  a  limb  is 
occluded  by  the  application  of  a  ligature.  Thus,  in  twenty-three 
cases  of  traumatic  aneurysm  of  recent  development,  the  average 
difference  in  the  peripheral  blood-pressure  between  the  normal  and 
the  injured  limb  amounted  to  21'4  mm.  of  mercurj^  when  tested  by 
the  manometer. 

The  amount  of  fall,  in  the  case  of  an  untreated  aneurysm. 
probably    decreases    with    time    and    development    of   the    collateral 


42        aiWSIIOT    IXJl  RIKS    TO    THE    HL()()1)-]'ESSELS 

circulation  ;  thus,  in  a  case  of  ancurvsnial  varix  of  the  suj^crficial 
femoral  of  seven  months'  standing,  the  distal  pressure  had  risen  to 
nearly  normal,  again  falling  after  an  operation  for  the  cure  of  the 
condition. 

Support  to  the  belief  that  an  obstruction  in  the  arterial  circula- 
tion throws  increased  strain  on  the  central  organs  is  also  afforded  by 
the  experience  of  the  frequency  with  which  the  operation  of  ligature 


Fig.    17. — Woiuid  of  popliteal  vessels.     Position  of  heart  during  inspiration. 
Skiagram  by  Capt.  Stone. 

of  an  artery  for  the  cure  of  a  spontaneous  anemysm  in  the  limbs  is 
followed  by  the  development  of  one  in  the  thorax. 

AY'ith  regard  to  the  evidence  of  cardiac  dilatation  afforded  by 
determination  of  the  position  of  the  apex;  of  37  cases  in  which  cardiac 
mtu-murs  accompanied  the  presence  of  an  aneurysm,  in  24  the  apex 
was  in  the  nipple  line,  in  4  Avithin  that  line,  and  in  9  it  was  from 
half  an   inch   to   two   and   a   half  inches    outside.      In   the   majority 


SYMPTOMS    AND   SIGNS 


43 


of  instances   the   vertical    level   tended  to   be  raised,   often  into  the 
fourth  interspace. 

Radiographic  examinations  have  been  made  in  a  few  cases  during 
the  early  stages  of  treatment,  and  the  illustrations  (/'^i^.s-.  17,  IS,  19, 
20)  are  highly  interesting.  Figs.  17  and  18  depict  the  size  and 
position  of  the  heart  in  inspiration  and  expiration  respectively.     They 


Fig.   18. — Same  case  as  Fig.   17.     Position  of  heart  during  expiration. 
Skiagrmn   by  Capt.  Stone. 


were  taken  from  a  patient  with  a  popliteal  varix  of  four  days'  standing, 
in  whom  the  position  of  the  apex  had  been  determined  by  palpation 
as  being  in  the  nipple  line.  It  will  be  observed  that  this  position 
during  expiration  is  more  than  confirmed,  while  during  inspiration, 
except  for  a  slightly  increased  extent  of  the  shadow  to  the  right  of 
the  sternum,  nothing  abnormal  is  to  be  observed.  In  the  investiga- 
tion of  another  case,  it  was  pointed  out  to  me  by  Captain  ]McIlwaine 


44        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

that  an  exactly  similar  condition  had  been  observed  by  him  in  a 
certain  number  of  the  patients  sent  to  the  base  with  the  service 
diagnosis  'disorderly  action  of  the  heart.'  Figs.  19  and  20  were 
taken  from  such  a  case  by  Captain  Crymble,  and  the  striking  resem- 
blance of  the  two  sets  of  skiagrams  is  obvious. 

Captain  Mcllwaine   further  kindly  imdertook  the   cardiographic 


Fig.  19. — Case  of  '  disorderly  action  of  the  heart.'     Position  of  heart  during  inspiration. 
Skiagram  by  Capt.   Crymble. 

investigation  of  foiu'  patients  suffering  from  woiuids  of  the  vessels, 
and  furnished  me  with  the  following  brief  reports  of  the  cases. 

Femoral  Arterial  Aneurysm. — Womided,  July  5,  1916.  Examined, 
July  18.  There  was  marked  pulsation  visible  in  the  3rd  and  4th 
interspaces.  The  beat  of  the  heart  was  forcible  and  diffuse,  not 
heaving.  The  apex  beat  was  felt  in  the  4th  and  5th  spaces  just 
outside   the   nipple   line.     No   murmiu-s    were   present.     The   electro- 


SYMPTOMS    AND    SIGNS 


45 


cardiogram   was   normal,   showing    no    right   or   left  ventricular   pre- 
ponderance.    General  blood-pressnrc  :    systolic,  140  ;    diastolic,  75. 

Femoral  Arterio-venou.s  Aneurysm. — Wounded,  A.n^.  15,  3  916. 
Examined,  Sept.  3.  Visible  pulsation  was  present.  The  apex  beat 
was  in  the  4th  space  just  round  the  nipple.  It  was  forcible,  but  not 
heaving.     A   systolic   murmur  Avas   present   at  the   apex   and   in   the 


Fig.  20.- 


-Same  case  as  Fig.   19.     Position  of  heart  during  expiration. 
Skiagram  by  Capt.  Crymble. 


pulmonary  area.  The  apical  murmur  was  not  conducted  towards 
the  axilla  :  it  was  modified  by  respiration.  Blood-pressure  :  systolic. 
120  ;  diastolic,  60.  The  electrocardiogram  showed  no  evidence  of 
any  ventricular  preponderance. 

Femoral  Arterio-venous  Aneurysm. — Wounded,  June  5,  1916. 
Examined,  Sept.  12.  The  apex  was  in  the  5th  space  half  an  inch  inside 
the  nipple  line.     Over  the  pra^cordia  there  was  a  forcible  beat,  not 


46        GUNSHOT    IX JURIES    TO    THE    BLOOD-VESSELS 

heaving.  This  pulsation  was  ^•isible.  There  was  a  well-marked 
systolic  murniiir  at  the  apex,  not  conducted  outwards.  There  Avas 
also  a  systolic  murmur  at  both  areas  at  base,  the  aortic  area  murmur 
being-  the  louder,  and  a  loud  aortic  second  sound.  Blood-pressure  : 
systolic,  155  ;  diastolic,  70.  The  electrocardiogram  showed  no  definite 
evidence  of  any  ventricular  preponderance.  The  heart  did  not  appear 
enlarged  in  the  skiagram  taken. 

Femoral  Arterial  Aneurysm. — Wounded,  Sept.  27, 1916.  Examined, 
Oct.  9.  There  was  a  visible  wave  of  pulsation  over  the  3rd  and  4-th 
spaces.  The  apex  beat  was  in  the  4th  space  just  inside  the  ni])ple 
line,  A  deep  inspiration  caused  the  beat  at  this  point  to  disappear, 
and  the  most  forcible  beat  appeared  in  the  5th  space  half  an  inch 
inside  the  nipple  line.  There  was  an  aj^ical  and  basal  systolic  murmiu', 
modified  by  respiration,  best  heard  during  expiration.  The  skiagram 
showed  that  the  cardiac  shadow  was  markedly  altered  by  respiration, 
being  pear-shaped  in  deep  inspiration  and  a  flattened  lateral  oblong 
in  expiration.  There  was  no  evidence  in  the  electrocardiogram  of 
any  ventricular  preponderance.  Blood-pressure  :  systolic,  122  ;  dias- 
tolic, 60.     There  was  a  loud  knock  in  the  artery. 

These  observations  seem  opposed  to  the  view  that  actual  dilata- 
tion of  the  heart  was  present.  In  fact  they  rather  suggest  that  a 
want  of  tone  in  the  heart  muscle — and  hence  a  condition  favourable 
to  an  exaggeration  of  the  changes  of  shape  of  the  organ  accompanying 
the  respiratory  movements — accounts  for  the  outward  displacement 
of  the  cardiac  apex. 

It  is  a  striking  fact  that  the  cardiac  conditions  so  nearly 
resemble  those  met  with  in  some  of  the  unwounded  men  sent  down 
from  the  front  with  the  diagnosis  'disorderly  action  of  the  heart.' 
Yet  it  does  not  seem  reasonable  to  assume  that  the  subjects  of  arterial 
wovuids  in  whom  such  signs  are  so  frequently  present  were  already 
suffering  from  'disorderly  action  of  the  heart'  when  they  received 
their  wound  ;  but  rather,  that  the  vascular  injury  has  led  to  the 
development  of  the  condition. 

The  patients  in  Avhom  these  cardiac  disturbances  are  present  do 
not  suffer  from  pra^cordial  distress,  rapid  respiration,  or  any  pain. 
On  inspection,  the  apex  beat  is  observed  to  be  displaced  and  abnor- 
mally visible,  while  diffuse  pulsation  is  frequently  apparent  over  the 
whole  prjecordial  area.  Acceleration  of  the  pulse  is  a  constant  sign, 
the  rate  varying  from  80  to  120,  with  a  mean  average  of  about  100. 
An  irritable  character  is  common,  and  in  some  cases  the  'knocking' 
type,  more  freely  discussed  below,  is  found.  The  symptoms,  Avhile 
not  constant,  are  extremely  common  in  connection  with  arterial 
woiuids,  although  their  prominence  does  not  always  coincide  with 
the    importance    of   the    vessel    implicated.     Without    doubt    cardiac 


SYMPTOMS    AND    SIGNS  47 

idiosyncrasy,  temperament,  and  perhaps  indnlgence  in  tobacco  may 
be  contributory  causes,  and  the  phenomena  are  certainly  i)i  part 
dependent  on  loss  of  blood.  It  may  be  well  to  emphasize  that  they 
have  been  observed  during  the  first  few  weeks  after  reception  of  the 
injuries,  and  tend  to  diminish  with  time.  With  all  these  reservations, 
however,  definite  evidence  exists  to  support  the  statement  that 
disordered  cardiac  action  follows  and  results  from  wounds  of  the 
large  arteries  and  the  formation  of  false  aneinysms. 

What  is  known  as  to  the  ultimate  course  of  arterio-venous 
aneurysms  and  varices  tends  to  support  the  view  that  extra  strain 
is  thrown  upon  the  heart  by  their  formation,  and  that  subsequent 
changes  take  place  in  the  peripheral  circulation.  Sir  W.  Osier,* 
while  pointing  out  that  the  changes  may  not  be  so  great  in  the  case 
of  vessels  of  the  upper  as  in  those  of  the  lower  limb,  says,  "  In  the 
majority  of  cases  venous  stasis  forms  the  most  serious  sequel  of  the 
disorder.  The  changes  in  the  arteries  on  the  proximal  side  of  the 
lesion  are  less  striking,  but  sooner  or  later  sclerosis  occurs  with  dilata- 
tion, and  sometimes  with  saccular  aneurysm  opposite  the  orifice  of 
the  communication.  Even  within  two  months  of  the  injury  the 
femoral  artery  may  be  felt  to  be  larger  and  with  stronger  pulsation." 
Observation  during  the  course  of  operations  of  the  exposed  vessels 
in  a  number  of  recent  cases  in  the  present  war  has  not  impressed  me 
with  the  occurrence  of  early  proximal  dilatation  ;  on  the  other  hand, 
distal  contraction  has  been  a  constant  feature,  either  in  pure  arterial 
injuries  or  in  arterio-venous  lesions,  as  will  be  referred  to  below.  It 
is  obvious,  however,  that  in  the  early  stages,  during  which  the  patient 
is  kept  at  rest  in  the  recumbent  position,  any  considerable  arterial 
dilatation  is  unlikely  to  develop.  During  the  performance  of 
operations  undertaken  at  a  later  period,  the  artery  on  the  proximal 
side  of  a  traumatic  aneurysm  is  generally  found  to  be  thickened  and 
dilated,  but  it  may  be  remarked  that  a  similar  condition  is  found 
also  when  the  lesion  is  purely  arterial  in  character. 

It  is  of  much,  interest,  in  ^dew  of  the  early  cardiac  conditions 
above  dealt  with,  to  quote  again  from  Sir  W.  Osier  ;  he  says,  "  One 
of  m}^  patients  died  from  heart  disease,  which  may  have  had  some 
connection  with  his  long-standing  lesion."  Again,  "  In  an  arterio- 
venous communication  in  the  middle  of  Scarpa's  space  established  in 
1898,  at  the  time  of  death,  in  1911,  the  dilated  arteries  extended 
from  the  bifiu'cation  of  the  common  iliac  to  the  lo^\er  third  of  the 
thigh.  PI}q3ertro]3hy  of  the  heart  followed,  and  death  from  progressive 
failure   of  the    circulation."     In  rare  instances   signs  and  symptoms 


Remarks  on  Ai-terio-venoiis  Aneurysms,"  Lancet,   1915,  i,  952. 


48        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

of  cardiac  disease,  in  which  respiratory  distress  and  general  a'dema 
are  marked  features,  have  been  observed  to  develop  a  few  weeks 
after  the  ])rimary  injury,  such  cases  ending-  fatally.  I  liave  ne\-er 
witnessed   this   result   myself. 

Cardiac  Murmurs — A  matter  of  interest,  which  has  apparently 
esca^^ed  previous  recognition,  lies  in  the  frequent  transmission  of  the 
local  systolic  arterial  bruit  to  the  heart,  and  hence  the  presence  of 
cardiac  systolic  murmius  of  a  pronounced  character  accompanying 
wounds  of  certain  of  the  blood-vessels. 

The  natiu'c  and  exi^lanation  of  these  murmurs  is  not  altogether 
simple,  for  they  are  temporary,  inconstant  in  occiu'rence,  and  heard 
especially  in  connection  with  certain  vessels.  The  last  fact  introduces 
some  difficulties  as  to  the  actual  mode  of  their  conduction  or  trans- 
mission ;  hence  it  may  be  as  well  to  deal  with  one  question  as  a 
preliminary — namely,  whether  the  cardiac  bruits  are  pureh^  ha-mie  in 
nature. 

That  ha;mic  cardiac  murmurs  are  not  infrequent  as  a  result  of 
serious  loss  of  blood  is  a  well-recognized  fact,  and  has  been  verified 
in  many  cases  ;  moreover,  in  one,  a  loud  apical  systolic  murmur 
accompanying  a  local  bruit  over  the  site  of  a  wounded  posterior  tibial 
artery,  was  replaced  by  a  soft  ha?mic  murmur  which  persisted  for 
twenty-four  hours  after  the  woimded  artery  had  been  occluded  by 
ligature.  This  observation  suggests  that  in  some  instances  a  com- 
poiuid  of  factors  may  account  for  the  presence  of  the  cardiac  murmur  ; 
but  the  above  was  an  isolated  experience,  and  in  other  observed  cases 
ligature  of  the  wounded  vessel  has  been  followed  by  immediate 
disappearance  of  the  cardiac  bniit.  When  the  experiment  is  made 
of  trying  to  abolish  the  cardiac  bruit  by  pressure  on  the  vessel 
proximal  to  the  wound,  it  is  found  that  absolute  suppression  of  the 
blood  current  is  required  to  banish  the  bruit  entirely. 

In  pure  arterial  injuries  the  miu'mur  is  loudest  at  the  cardiac 
apex,  or  often  over  the  base  of  the  left  ventricle,  and  the  sound 
is  not  conducted  towards  the  axilla  or  the  neck.  When  present,  the 
murmiu's  are  loud  and  distinct  as  a  rule,  and  are  indistinguishable  in 
character  from  those  present  in  mitral  valvular  disease.  It  is  remark- 
able that  in  some  cases  the  cardiac  bruit  may  be  much  louder  than 
the  local  murmur  indicating  the  woiuided  spot  in  the  vessel.  This 
feature  is  the  more  surprising,  in  that  the  local  arterial  murmur  is 
commonly  conducted  more  widely  in  the  distal  than  in  the  central 
direction. 

In  arterio- venous  aneiu'ysms  or  aneiuysmal  varices  the  venous 
hum  is  continuous,  while  the  systolic  element  is  commonly  the  more 
pronounced,  and  possibly  accentuated  by  a  prolongation  of  the 
•diastolic    phase.     In    femoral    arterio-venous    aneiuysms    the    venous 


SYMPTOMS    AND   SIGNS  49 

roar  is  sometimes  absent,  and  when  the  communication  is  situated  in 

the  neck  or  axilla,  the  continuous  venous  roar  is  usually  the  only 

element.     The  conveyed  murmurs  are  only  common  when  the  vessels 

of  the  lower  extremity  are  concerned,  and  arc  then  generall};'  most        ,/ 

pronounced    over    the    base    of    the    heart.     When    the    murmurs 

commence  to  fail  in  strength,  the  systolic  element  is  usually  the  first 

to  disappear. 

Amongst  180  cases  of  arterial  lesions  in  which  a  routine  examina- 
tion was  made  with  the  object  of  searching  for  cardiac  murmurs, 
these  were  present  in  37  ;  18  of  the  lesions  were  arterio-venous,  19 
purely  arterial. 

The  date  of  appearance  of  the  murmurs  is  early,  probably  as  a  , 
rule  immediate,  but  in  some  instances  a  day  or  two  may  elapse  before 
they  become  evident.  Four  cases  of  delayed  appearance  are  included 
among  the  numbers  given  above.  Considerable  variations  in  strength 
and  tone  may  occur  from  day  to  day,  but  the  general  tendency  is 
towards  diminution  and  disappearance  of  the  sounds.  The  longest 
period  in  which  any  murmur  was  noted  to  j^ei'sist  in  men  recently 
wounded  was  seventy  days,  but  many  patients  in  whom  the  arterial 
wound  was  untreated  returned  to  England  with  the  bruit  still  audible. 

Experience  has  shown,  however,  that  the  conveyed  murmurs  may 
persist  for  a  long  period  ;  also  that,  after  subsiding  during  a  jDeriod 
of  rest,  they  may  return  with  the  resumption  of  active  life.  Thus,  a 
brachial  arterio-venous  communication  of  six  years'  standing  was 
detected  as  a  result  of  the  discovery  of  an  abnormal  cardiac  bruit 
during  an  ordinary  routine  examination  made  for  medical  purposes  ; 
and  I  have  seen  other  instances  in  which  a  primary  diagnosis  of  cardiac 
disease  needed  to  be  revised  in  consequence  of  the  discovery  of  a 
local  vascular  lesion  in  the  limbs.  It  is  in  this  last  respect  that  the 
conveyed  murmurs  acquire  their  chief  practical  importance,  since  it 
is  obvious  that  their  discovery  may  lead  to  the  detection  of  a  lesion 
that  might  otherwise  be  readily  overlooked,  especially  in  the  svibjects 
of  multiple  small  gunshot  wounds. 

Local  Vascular  Murmurs. — The  characters  of  the  typical  local 
murmurs  are  well  known  and  recognized,  but  some  remarks  on  the 
conditions  which  may  affect  the  sounds  in  individual  cases  may  not 
be  out  of  place.  Moreover,  it  is  not  perhaps  even  now  generally 
recognized,  that  a  local  systolic  murmur  is  the  most  certain  and  easily 
obtained  proof  of  a  wound  of  a  deeply  situated  artery. 

Considerable  variations  of  tone  and  character  are  met  with. 
Thus,  the  arterial  wound  may  be  indicated  by  a  soft  'bellows'  murmm- 
(especiall}^  when  there  is  great  swelling  of  the  limb),  a  loud  'rushing" 
sound,  or  a  musical  whistle,  the  latter  commonly  in  the  later  stages 
when  cicatrization  is  advanced.     In  the  presence  of  an  arterio--\'enous 

4 


50        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

communication,  citlier  the  systolic  bruit  or  the  venous  roar  may  be 
tlie  more  prominent  element  ;  in  some  cases  the  buzzing  sound, 
compared  to  the  noise  made  by  'a  bee  in  a  bag, '  is  the  salient  feature  : 
in  others  the  venous  roar  assumes  the  character  of  a  deep  pedal  note. 
No  characteristic  differences  have  been  observed  between  the  murmurs 
accompanying  the  contused  woimd  produced  by  the  bullet  and  the 
often  comparatively  cleanly-cut  opening  produced  by  sharp  fragments 
of  shells  or  bombs.  Neither  does  the  loudness  of  the  sound  correspond 
with  the  size  of  the  vessel  concerned,  although  a  superficial  position 
of  the  vessels  is  of  much  importance  in  this  resiDcct. 

A  number  of  factors,  to  which  it  is  difficult  to  assign  the  proper 
relative  import,  do,  however,  doubtless  affect  both  the  character  and 
strength  of  the  bruit  produced.  Thus,  the  nature  of  the  apertiu'c  may 
be  mentioned  :  in  some  cases  marginated  by  a  ragged  ring  of  the  media, 
in  others  by  a  thin  sharp  margin  of  bare  intima  from  which  the  media 
has  been  stripped,  while  in  still  others  a  ragged  tongue  of  media  may 
project  across  an  arterio-venous  opening.  Again,  the  timbre  of  the 
bruit  tends  to  change  in  accordance  with  the  stage  of  stiffening  from 
infiltration  or  cicatrization  which  has  been  reached.  Lastly,  the  depth 
of  tone  and  resonance  of  the  sound  is  affected  by  the  length  of  the 
column  of  blood,  the  size  of  the  cross-section  of  the  vessels,  the 
presence  of  a  large  collection  of  fluid  blood  or  clot  in  connection  with 
the  wound  in  the  vessel,  and  the  general  conformation  of  the  patient 
himself.  It  is  obvious  that  the  mass,  strength,  and  degree  of  tension 
of  the  structures  of  a  limb  are  of  importance  as  resonating  factors, 
and  these  are  still  more  evident  when  the  woiuided  vessel  is  situated 
over  the  chest  wall,  or  in  the  close  vicinity  of  hollow  viscera. 

In  connection  with  the  comparative  resonance  of  different  limbs, 
an  observation  made  in  employing  percussion  to  elicit  the  tjaiipanitic 
note  present  when  a  limb  is  deeply  infiltrated  with  gas  is  of  some 
interest.  This  sign,  to  which  considerable  importance  is  rightly 
allotted,  may  be  vitiated  by  the  presence  of  either  a  large  woiuid 
defect  or  the  existence  of  a  considerable  collection  of  effused  blood 
in  a  limb,  especially  around  a  fracture.  Either  of  these  conditions 
may  accompany  a  wounded  artery,  and  the  altered  acoustic  conditions 
will  no  doubt  affect  the  character  of  a  murmiu'. 

Certain  other  features  arc  worthy  of  further  consideration  ;  but 
before  proceeding  to  them,  the  occurrence  of  systolic  arterial  bruits 
independent  of  an  open  arterial  wound  should  be  mentioned.  These 
may  depend  upon  obstruction  to  the  arterial  huiien,  diie  either  to 
cicatricial  contraction  of  the  vessel  itself,  or  to  pressure  from  Avithout. 
Such  murmurs  are  distinctly  rare  in  my  experience.  I  haAC  auscultated 
many  hundreds  of  arteries  in  the  search  for  wounds,  and  among  these 
may  be  particularly  mentioned  a  series  in  which  the  distal  pulse  was 


SYMPTOMS    AND   SIGNS  51 

diminished  or  absent  in  injuries  about  the  root  of  the  neck  and 
shoulder.  In  sueh  cases  complete  severance  of  the  vessel,  obstruction 
from  thrombosis,  or  external  pressure  by  displaced  fragments  of  bone 
is  to  be  expected  ;  but  in  very  few  instances  has  a  murmur  been 
detected,  and  this  a  'whistling'  at  a  late  stage  after  the  injury, 
probably  due  to  cicatricial  changes. 

A  local  vascular  murmur  may  be  very  considerably  modified  by 
pressure  exerted  by  the  bell  of  the  stethoscope  ;  this  may  accentuate 
it  as  well  as  alter  the  timbre.  In  an  instance  in  which  a  pure  systolic 
bruit  was  audible  over  a  traumatic  aneurysm  of  the  femoral  artery, 
jDressure  by  the  stethoscope  produced  a  soft  cooing  sound,  somewhat 
resembling  the  musical  sigh  often  heard  among  trees  in  a  soft  breeze 
at  night. 

It  is  not  uncommon  for  a  murmur  to  be  audible  over  the  site 
of  a  sutured  arterial  wound,  when  either  the  lumen  is  narrowed  for 
a  considerable  longitudinal  extent,  or  when  a  sudden  narrowing  is 
present.  These  bruits  closely  resemble  those  accompanying  the 
presence  of  an  open  wound.  A  somewhat  striking  experimental 
proof  of  the  capacity  of  incomplete  obstruction  to  the  arterial  lumen 
to  give  rise  to  a  murmur  audible  in  the  heart,  is  afforded  by  an 
observation  made  during  the  use  of  Tufher's  arterial  tubes.  In  two 
such  cases  a  systolic  bruit  was  audible  at  the  apex  of  the  heart  after 
the  introduction  of  the  tube,  disappearing  with  its  removal. 

Another  not  infrequent  phenomenon  is  the  presence  of  a  systolic 
bruit,  audible  throughout  the  great  vessels  of  the  body,  developing  in 
consequence  of  a  severe  secondary  haemorrhage.  Its  interest  depends 
upon  its  resemblance  to  the  haemic  cardiac  murmurs  so  much  more 
commonly  present  under  like  circumstances,  and  thus  it  brings  the 
two  conditions  into  accord.  It  is  remarkable  that  in  one  instance  in 
Avhich  this  general  arterial  bruit  was  well  developed,  no  similar 
murmur  was  audible  over  the  heart ;  but  it  may  be  added  that  the 
patient  at  the  time  of  examination  was  within  a  few  hours  of  death. 

A  much  more  common  occurrence  as  a  sequence  of  haemorrhage 
is  the  development  of  a  general  arterial  bruit  of  the  'pistol  shot'  or 
'water  hammer'  type.  The  assumption  of  this  type  may  again  be 
quite  indei^endent  of  an  arterial  wound,  but  it  gains  interest  in 
this  relation  from  the  fact  that  it  materially  modifies  the  character 
of  the  murmurs  audible  over  an  aneurysm  when  it  is  present.  This 
'pistol  shot'  character  has  been  referred  to  bj^  Sir  W.  Osier,*  and  I 
adopt  the  term  from  him,  as  much  more  nearly  describing  the  soimd 
than  the  term  'slamming'  I  was  accustomed  to  make  use  of.     As  a 


Loc.  cif.,  p.  953. 


52       GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

generalized  phenomenon  it  is  often  heard  in  its  most  pronounced  form 
in  patients  dying  from  acute  toxa?mia,  or  in  joatients  at  the  end  of  a 
long  and  trying  operation  during  which  much  blood  has  been  lost. 
In  this  form  the  sound  suggests  the  falling  of  drops  of  water  in  an 
empty  tube,  and  caiises  an  actual  shock  to  the  tympanic  membrane 
of  the  auscultator  with  each  beat  of  the  heart.  The  probability  of 
its  presence  is  indicated  with  some  certainty  by  the  character  of  the 
pulse  on  palpation,  a  similar  'knock'  being  felt.  When  this  general- 
ized sound  is  present,  it  naturally  accentuates  and  modifies  the  local 
murmiu"  audible  over  an  arterial  aneurysm  or  an  arterio-venous 
communication  ;  but  it  is  an  interesting  fact  that  the  local  murmur 
may  assume  the  same  character  when  it  is  not  present  in  the  arteries 
generally. 

This  t3"pe  of  sound  can  be  readily  reproduced  experimental!}^  by 
lowering  the  diastolic  pressure  in  an  artery  of  an  extremity  by  applying 
the  arm  band  of  an  ordinary  manometer  ;  in  fact,  as  pointed  out  to 
me  by  Captain  Mcllwaine,  by  the  ordinary  auscultatory  method 
employed  in  determining  the  blood-pressvu'c.  When  the  band  has 
been  tightened  for  some  seconds,  and  is  then  relaxed,  the  early  beats 
of  the  artery  distal  to  the  compressing  band  are  audible,  and  of  the 
true  '  pistol  shot '  type.  By  this  observation  definite  support  is  afforded 
to  the  view  that  the  diversion  of  a  portion  of  the  blood-stream 
through  an  abnormal  opening  lowers  the  distal  blood-pressure  and 
interferes  materially  with  the  blood-supply  of  the  limb  beyond  the 
wound,  conditions  calling  for  increased  effort  on  the  part  of  the  heart 
to  maintain  the  vitality  of  the  limb.  The  fact  that  the  local  pheno- 
menon is  inconstant  is  readily  ex23lained  by  the  condition  commonly 
observed  Avhen  wounded  arteries  are  exposed  for  the  purpose  of  ligation 
or  suture.  In  these  circumstances  the  portion  of  the  vessel  distal 
to  the  wound  is  found  to  be  considerably  contracted,  and  this  to  an 
extent  apjDroximating  to  that  seen  when  the  vessel  has  been  completely 
severed.  I  have  noted  this  condition  as  late  as  seven  months  after 
the  reception  of  a  lateral  wound  of  the  femoral  artery  which  took 
part  in  an  aneurysmal  varix,  so  that  the  compensating  contraction 
may  be  more  or  less  permanent.  This  contraction  is  no  doubt 
sufficient,  in  a  great  number  of  cases,  to  corresj^ond  with  the  diminished 
amount  of  blood  able  to  reach  the  artery  ;  hence  a  sufficient  diastolic 
pressure  is  maintained  to  obviate  the  occurrence  of  the  'pistol  shot' 
sound.  If,  on  the  other  hand,  the  compensatory  contraction  is  in- 
sufficient as  a  result  of  the  large  amount  of  blood  diverted  from  the 
normal  current,  or  possibly  as  a  consequence  of  disturbance  of  the 
normal  vasomotor  reaction  causing  actual  peripheral  dilatation,  the 
'pistol  shot'  character  is  assumed  by  the  aneiuysmal  nuu-mur.  This 
view  is  further  supported  by  the  observation  that  the  'pistol  shot' 


SYMPTOMS    AND   SIGNS  5.3 

sound  is  far  more  common  in  artcrio- venous  than  in  arterial 
aneurysms  ;  and  this  because  a  much  larger  amount  of  blood  can  be 
diverted  into  the  lumen  of  the  vein— whence  it  can  readily  pass 
onwards  with  the  reverse  circulation — than  can  be  possible  in  the 
case  of  the  cavity  of  an  arterial  aneurysm,  which  is  of  more  or  less 
constant  dimensions. 

In  connection  with  the  general  explanation  offered  above  of  the 
mode  of  production  of  the  'pistol  shot'  sound,  it  may  be  suggested 
that  when  in  arterio-venous  lesions  this  is  local  only,  the  'knock'  may 
be  produced  by  the  direct  passage  of  the  powerful  arterial  stream 
into  the  dilated  venous  channel,  in  which  the  pressure  is  comparatively 
low. 

Mode  of  Transmission  of  Local  Aneurysmal  Murmurs  to  the 
Heart. — Before  proceeding  directly  to  the  consideration  of  the  mode 
of  conduction  of  local  vascular  murmurs  to  the  heart,  it  may  be 
convenient  to  recall  that  the  conduction  of  the  murmurs  in  the  limbs 
themselves  varies  considerably  both  in  extent  and  distribution. 

In  purely  arterial  lesions  the  murmur  is  loud,  and  can  be  heard 
more  widely  in  the  distal  than  in  a  central  direction.  Centrally  it  is 
rare  to  be  able  to  trace  the  sound  more  than  a  few  inches.  Further, 
the  murmur  is  practically  limited  in  distribution  to  the  line  of  the 
vessels  themselves  and  the  area  of  the  limb  occupied  by  the  aneurysmal 
sac,  if  one  is  present. 

In  arterio-venous  lesions,  the  murmurs  are  conducted  in  both 
directions,  the  double  bruit  often  the  entire  length  of  tbe  limb,  while 
in  the  central  direction  the  venous  roar  is  always  conducted  widely. 
In  some  instances  the  conduction  is  limited  to  the  line  of  the  vessels, 
in  others  the  vibrations  are  transmitted  to  the  whole  mass  of  the 
tissues  of  the  limb,  and  audible  in  whatever  position  the  stethoscope 
is  applied.  This  latter  phenomenon  is  no  doubt  explained  by  the 
comparative  strength  of  the  vibration  caused  by  the  meeting  and 
mixing  of  the  ciu'rents,  which  is  further  indicated  by  the  palpable 
thrill  commonly  present  over  the  vessels.  Perhaps  to  a  lesser  extent 
it  may  be  influenced  by  the  tone,  tension,  and  strength  of  the 
individual  limb.  In  relation  to  the  inconstancy  of  the  transmission  of 
the  vibrations  to  the  limb  generally,  it  may  be  remarked  that  the 
sign  of  'purring  or  bubbling  thrill'  is  very  variable  both  in  strength 
and  occurrence.  In  some  cases  it  is  difficidt  to  determine,  and  in  all 
it  is  a  very  uncertain  guide  to  the  exact  location  of  the  arterio-venous 
communication.  The  same  may  be  said  when  the  vein  is  exposed  ; 
thus,  the  wall  of  the  internal  jugular  vein  may  in  some  cases  be  seen 
to  'shiver'  ;  in  others  the  vibration  is  not  visible.  Definite  vibration 
on  the  surface  of  the  neck  is  also  occasionally  seen.  Venous  jDulsation 
is  not  often  visible   independently  of  the  arterial  pulsation  excejDt   at 


54       GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

the  root  of  the  neck.  Of  the  entire  number  of  cases  I  have  seen,  in 
only  tAvo  instances  in  the  limbs — (a)  where  the  brachial  artery  at 
the  bend  of  the  elbow  was  in  communication  with  the  median  basilic 
vein  ;  and  {h)  when  the  cephalic  vein  had  been  laid  bare  by  incision 
of  the  pectorals  for  exploration  of  an  axillary  arterio-venous  aneiu'ysm 
— was  independent  venous  pulsation  palpable  and  visible. 

It  is  a  remarkable  fact  that  conduction  of  the  local  systolic 
murmur  to  the  heart  is  uncommon  luiless  the  w^ounded  vessel  is 
situated  in  the  low^er  extremity  ;  and  the  same  remark  applies  in  a 
lesser  degree  to  the  arterio-venous  bruits,  with  the  definite  reserva- 
tion of  the  cases  in  which  the  tissues  generally  conduct  the  murmur 
to  the  cardiac  area.  Amongst  a  large  series,  the  murmur  accompany- 
ing a  local  injury  to  the  artery  alone  w^as  audible  in  the  heart  in  6  out 
of  24  axillary  aneurysms,  and  in  only  one  instance  of  arterial  aneurysm 
of  either  the  neck  or  arm.  On  the  other  hand,  amongst  94  cases  of 
arterial  aneurysm  in  the  lower  extremity,  the  systolic  murmur  was 
conducted  to  the  heart  in  no  less  than  31  instances.  Moreover,  the 
murmur  is  equally  loud  and  pronounced  whether  the  local  injury  is 
situated  in  the  vessels  of  the  thigh  or  the  leg.  Again,  as  has  been 
already  remarked,  the  loudness  of  the  cardiac  murmur  in  no  way 
corresponds  with  that  heard  over  the  wounded  spot  in  the  vessel  or 
the  aneurysm,  for  the  latter  may  be  soft  while  the  conducted  miu-mur 
in  the  heart  is  loud  and  pronounced. 

It  does  not  appear  easy  to  explain  this  difference  in  regard  to 
transmission  of  the  local  murmur  from  the  vessels  of  the  lower 
extremity  and  those  of  the  remaining  parts  of  the  body.  It  is  difficult 
to  assume  any  other  path  of  conduction  than  the  vessel  wall  and  the 
cohmin  of  blood  contained  by  it,  and  this  path  is  uninterrupted  in 
the  case  of  all.  It  is  clear  that  the  comparative  distance  of  the  lesion 
from  the  heart  exerts  little  or  no  difference,  unless  the  resonating 
power  of  the  column  of  blood  be  increased  by  its  length ;  and  if  this 
be  the  case  there  seems  no  reason  w^hy  the  systolic  arterial  mia-miu' 
should  not  be  audible  in  any  part  of  the  column  of  blood  and  vessel 
wall  connecting  the  lesion  with  the  heart.  Another  explanation  to 
hand,  lies  in  the  direct  transit  by  vessels  wdiich  make  no  turns  and 
gradually  increase  in  size  from  their  termination  to  their  origin  in 
the  heart.  These  conditions  are  present  in  the  vessels  of  the  low^er 
extremity,  while  in  the  case  of  the  upper,  a  fairly  sharp  bend  is  made 
as  the  vessels  emerge  from  the  thorax,  and  both  in  these  and  the 
vessels  of  the  neck  a  very  sharp  contrast  of  calibre  exists  where  they 
originate  from  the  aorta.  This  difference  in  direct  course  and 
continuous  gradiuil  increase  in  size  seems,  therefore,  a  ready,  if  not 
an  entirely  convincing,  solution  of  the  question.  In  relation  to  the 
influence  of  direct  jiroximity  of  the  arterial  lesion  to  the  heart,  it  is 


SYMPTOMS    .INI)    SIGNS  55 

of  interest  to  note  that  in  the  only  case  observed  of  wound  of  the 
internal  mammary  artery,  a  systolic  murmur  was  loud  beneath  the 
third  left  costal  cartilage,  but  no  trace  of  it  was  to  be  detected  in 
the  heart. 

The  fact  that  the  systolic  murmur  accompanying  arterial  injuries 
is  transmitted  in  the  opposite  direction  to  the  arterial  blood-stream 
suggests  that  the  vibrations  may  be  mainly  conducted  by  the  arterial 
wall ;  and  if  this  be  the  case,  the  influence  of  change  of  direction  and 
sudden  increase  of  calibre  may  be  more  readily  intelligible.  In  the 
case  of  the  arterio-venous  brnits  this  question  is  not  of  equal  import- 
ance, but  transmission  by  the  wall  of  the  vein  is  still  more  easy  to 
accept.  The  most  probable  explanation  is  that  in  either  case  the 
sounds  are  conducted  by  the  venous  current. 

When  arterio-venous  communications  are  met  with  in  the  neck 
or  axilla,  the  continuous  min-mur  is  commonly  audible  over  the  whole 
cardiac  area,  but  the  normal  cardiac  sounds  can  usually  be  heard  quite 
distinct  from  the  adventitious  bruit.  In  these  instances,  however, 
the  murmur  may  be  continuously  traced  from  the  seat  of  the  vascular 
lesion  to  the  pra?cordial  region,  usually  diminishing  in  strength  as  the 
heart  is  reached.  This  phenomenon  therefore  rather  resembles  that  of 
the  general  conduction  of  the  arterio-venous  murmur  to  the  mass  of 
the  tissues  of  the  limbs,  the  advantage  of  the  sounding-board  provided 
by  the  chest  wall  facilitating  the  transit  and  intensifying  the  strength 
of  the  musical  vibrations.  When  the  arterio-venous  lesion  is  more 
distantly  placed,  the  difference  between  the  very  limited  central 
conduction  of  the  local  systolic  arterial  murmur,  and  the  long  extent 
which  intervenes  between  the  cessation  of  this  and  its  reappearance 
in  an  even  intensified  form  in  the  heart,  is  very  striking  ;  the  only 
explanation  which  comes  ready  to  hand  lies  in  the  fact  that  in  the 
vein  the  direction  in  which  the  sound  is  conducted  corresponds  to 
that  of  the  blood-stream,  while  the  arterial  murmur  requires  to  be 
transmitted  in  an  opposed  direction.  This  view  gains  support  from 
the  not  infrequent  observation  that  in  arterio-venous  conuiiunications 
situated  in  the  neck  or  axilla,  it  is  the  venous  roar  alone  that 
reaches  the  pra;cordial  area,  the  systolic  element  being  either  masked 
by  the  valvular  sounds,  or  being  suppressed.  Again,  even  in  the 
case  of  arterio-venous  communications  in  the  lower  extremity  in 
which  a  double  murmur  is  transmitted  to  the  heart,  the  systolic 
element,  often  at  first  the  more  pronounced,  fades  more  rapidly, 
and  often  becomes  quite  inaudible  or  disappears,  while  the  venous 
roar  persists. 

Signs  of  Disordered  Nerve  Function  accompany  many  arterial 
injuries,  and  should  be  mentioned  here,  although  they  are  seldom  of 
diagnostic  significance  in  the  early  stages  of  the  injuries.     They  acquire 


56       GUXSIIOT    INJURIES    TO    THE    BLOOD-VESSELS 

their  real  ini])ortiince  as  one  of  the  consequences  of  arterial  injuries, 
and  will  be  dealt  with  at  greater  length  in  Chapter  V. 

There  can  be  little  doubt  that  these  signs  are  for  the  most  part 
a  direct  result  of  interference  with  the  peripheral  blood-supply, 
although  in  some  of  the  recorded  instances  it  is  not  possible  altogether 
to  exchide  the  implication  of  the  peripheral  nerves  by  the  injury  ; 
but,  as  Captain  Burrows  has  pointed  out,  cases  do  occur  where  the 
injuries  to  the  vessels  are  of  a  partial  nature,  in  which  disturbances 
both  of  motor  action  and  sensation  appear  to  folloAv  a  purely  vascular 
lesion. 

Captain  Biutows,  in  an  interesting  paper,*  has  drawn  a  definite 
distinction  betw^een  the  character  of  the  signs  which  he  considers  are 
purely  ischsemic  in  origin,  and  those  which  he  suggests  are  'reflex'  in 
nature.  In  the  former,  anaesthesia  of  the  glove  or  stocking  type, 
subjective  sensations,  and  m\iscular  paralysis  accompanied  by  a  hard 
inelastic  condition  of  the  muscles  on  j^alpation,  are  met  with,  the 
abnormalities  of  sensation  being  confined  to  the  portion  of  the  limb 
distal  to  the  injury.  In  the  reflex  type,  widespread  cutaneous 
ana;sthesia,  sometimes  extending  well  above  the  level  of  the  Avound 
and  corresponding  with  no  definite  nerve  distribution,  is  combined 
with  motor  paralysis  in  which  the  mucles  are  soft  and  flaccid.  For 
the  reflex  type  he  suggests  the  name  'angiotic  paralysis.' 

LericheT  attributes  the  signs  of  disturbance  of  nervous  function 
accompanying  vascular  lesions  to  injury  to  the  perivasc\flar  sympa- 
thetic nerves  contained  in  the  arterial  sheath,  and  supports  this  view 
by  a  munber  of  cases  in  which  he  has  obtained  imj)rovement  in  the 
sjaiiptoms  by  performing  at  a  later  date  what  he  terms  perivascular 
sympathectomy,  i.e.,  excision  of  a  short  portion  of  the  sheath  and 
contained  nerves. 


*  British  Medical  Journal,  1918,  i,  Feb.,  p.  199, 
■\  Lyon  Chirurgicale,  1917,  xiv.  No.  4,  July,  p.  754. 


57 


CHAPTER    IV. 

ARTERIAL     HEMATOMA     AND     TRAUMATIC     FALSE 
ANEURYSM. 

Apart  from  external  hfernorrhage,  the  common  sequence  of  a  gun- 
shot wound  of  a  large  artery  is  the  development  of  an  arterial 
hsematoma,  usually  a  large  pulsating  collection  of  blood  lying  at  first 
diffused  in  the  tissues,  its  line  of  extension  being  dependent  on  the 
anatomical  arrangement  of  the  part  concerned.  The  most  character- 
istic are  those  which  develop  in  connection  with  comparatively  super- 
ficial vessels  such  as  the  common  femoral  or  the  third  part  of  the 
subclavian  ;  in  these  the  ha;matoma  is  commonly  accompanied  by 
widespread  ecchyrnosis  of  the  overl^dng  integument.  When  the 
deeper  vessels  are  wounded  ecchymosis  is  rare,  the  soft  fluctuating 
local  swelling  is  replaced  by  a  tense  general  swelling  of  the  limb, 
and  no  definite  limitation  of  the  extent  of  the  cavity  can  be  at  first 
determined. 

The  earliest  secondary  change  consists  in  coagulation  of  the 
effused  blood  at  the  circumferential  part  of  the  cavity,  which  i^rocess 
tends  to  check  primarily  any  further  extension  of  the  extravasation. 
As  the  ]3rocess  of  coagulation  proceeds,  shrinkage  of  the  resulting 
clot  takes  place,  with  the  result  of  producing  a  definitely  localized, 
pulsating  swelling  which  may  project  boldly  from  the  siu'face  of  the 
joart  of  the  body  affected.  The  extent  to  which  coagulation  may 
proceed  varies  ;  in  a  minor  proportion  of  the  cases  the  central  portion 
of  the  effusion  remains  fluid  in  direct  continuit}'^  with  the  contents 
of  the  wounded  artery,  and  the  condition  of  arterial  htematoma 
persists  for  some  time.  This  class  of  case  is  that  iriost  liable  to  suffer 
from  the  effects  of  infection  of  the  surrounding  tissues,  which  may 
result  in  secondary  extension  into  the  tissues,  or  secondary  hai'mor- 
rhage  from  the  external  wound.  It  is  most  frequently  met  with  in 
situations  such  as  Scarpa's  triangle  or  the  anterior  triangle  of  the  neck, 
in  which  the  blood  effusion  is  afforded  but  slight  support  by  the 
surrounding  structures. 

In  other  instances,  particvdarly  in  the  case  of  vessels  well 
supported  by  the  surrounding  structures,  the  entire  effusion  may 
become  metamorphosed  into  a  firm  clot,  and  the  primar)'^  systolic 
bruit  produced  by  the  woimd  in  the  artery  may  disappear  completely. 
If  a  primary  bruit  disappears,  we  may  assume  a  limited  lateral  wound 


58       GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 


of  the  artery  to  be  likely  {Fig.  21).  The  further  progress  of  sueh 
cases  varies  j  a  large  hard  clot  is  a  primary  cause  of  danger,  since 
it  tends  to  exert  very  firm  pressure  on  the  main  and  the  collateral 
vessels,    and   hence   gangrene  of  the  peripheral  part  of  the  limb    is 

apt  to  occur,  especially  if  the  femoral 
or  the  popliteal  artery  has  been 
wounded. 

A  more  common  result  is  the 
secondary  development  of  a  false 
aneurysmal  cavity.  The  impact  of 
the  blood-stream  opposite  the  defect 
in  the  arterial  wall  tends  to  hollow 
out  a  rounded  space  in  the  recently 
coagulated  blood,  or  to  regularize  the 
form  of  an)^  residual  space  remaining 
in  the  clot.  The  resulting  cavity 
acquires  a  boundary  formed  by  the 
deposition  of  well-marked  layers  of 
laminated  clot,  resembling  that  met 
with  in  typical  spontaneous  aneur- 
ysms. The  sacs  when  small  and  recent 
are  readily  separable  from  the  sur- 
rounding mass  of  conglomerate  prim- 
ary clot.  At  a  later  date  the  primary 
eoagulum  is  completely  absorbed,  and 
then  a  typical  false  aneurysm  remains. 
The  wall  of  the  j)rovisional  sac  is  thick- 
est at  the  point  most  distal  from  the 
arterial  wound,  becoming  gradually 
thinner  as  it  approaches  the  opening 
in  the  artery,  to  the  edges  of  Avhieh  it 
is  united  by  a  comparatively  tenuous 
layer.  AVhen  laid  open,  the  smooth, 
shining,  inner  surface  of  the  sac  sug- 
gests the  presence  of  an  endothelial 
lining,  even  at  an  early  stage  of 
development.  When  this  stage  has 
been  reached  the  designation  of  arter- 
ial ha^matoma  ceases  to  be  applicable, 
and  the  term  false  aneurysm  is  prefer- 
able, since  the  old  irregular  blood  cavity  is  gone  and  is  replaced 
by  a  distinctly  new  formation.  In  Fig.  22,  c  and  d  show  examples 
of  two  sueh  sacs,  developed  in  connection  with  the  posterior  tibial 
artery  ;    both  were  -sviped  out  of  the  deep  layers  of  the  calf  through 


Fig.  21. — Wound  of  the  right 
common  carotid  artery.  The  inter- 
ior of  the  vessel  is  occupied  by 
a  cylindrical  clot  starting  froin 
the  wounded  spot  and  extend- 
ing peripherally.  The  contracted 
thrombus  is  not  of  sufficient  cahbre 
completely  to  obstruct  the  blood- 
stream. Without  the  vessel  a  solid 
mass  of  clot  is  attached  to  the  wall. 
A  condition  of  sohdified  hematoma 
exists  which  might  be  followed  (a) 
by  spontaneous  healing  of  the 
wound  of  the  wall  of  the  artery,  or 
(b)  by  the  delayed  development  of 
a  false  aneurvsm. 


H.EM  ATOM  A  AND   TRAUMATIC  FALSE  ANFAJRYSM     50 


Fig.   22. — Theee  Small  False  Aneurysmal  Sacs  developed  in  connection  with 
Wounds   of  the  Posterior  Tibial  Artery  in  their  Early  Stage. 

The  largest  and  most  irregular  (a)  has  beside  it  the  artery  (6)  showing  a  small 
lateral  wound  and  one  of  the  vense  comites  also  wounded.  The  patient  from  whom  it 
was  removed  had  a  compound  fracture  of  the  leg,  the  wound  accompanying  which 
was  badly  infected.  Pulsation  and  a  purely  arterial  bruit  were  not  noted  until  the 
tenth  day.  On  the  fifteenth  day  secondary  haemorrhage  occurred,  and  the  limb  was 
amputated.      Under  the  care  of  Lieut. -Colonel  Butler. 

The  smallest  sac  (c)  is  fairly  symmetrically  globular  ;  the  hole  by  which  the 
wound  in  the  artery  communicated  with  it  is  well  shown,  also  the  tenuous  nature  of 
its  margins.  A  magnified  section  of  the  wall  of  this  sac  is  seen  in  Fig.  23.  Under  the 
care  of  Captain  Clementi  Smith. 

The  third  sac  (d)  resembles  the  two  others  in  character  ;  the  small  hole  commtmi- 
cating  with  the  lumen  of  the  artery  is  seen.  The  whole  structure  is  somewhat  tripartite 
in  outline,  but  the  two  secondary  masses  contain  only  a  small  cavity,  and  consist 
mainly  of  solid  clot.      Under  the  care  of  Captain  W.  G.  Mumford. 


Fig.  23. — A   Section   of   the   Wall    of   the    Small   Aneurysmal   Sac    shown    in 
Fig.  22  c,  magnified  to  demonstrate  its  Structure  (|  objective). 

The  wall  is  formed  by  interlaced  concentric  laminas  of  fibrin  and,  within  the  meshes 
of  the  network,  blood-corpuscles.     No  fibrous  tissue  has  yet  been  developed. 


60        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

incisions  made  to  evacuate  large  masses  of  clot  wiHi  which  their 
connection  hjid  been  severed. 

In  the  case  of  larger  vessels,  when  haemorrhage  necessitates  an 
early  operation,  similar  cavities  arc  foimd  in  the  clot  and  in  connection 
^vith  the  open  woimd  in  the  artery  ;  but  the  main  wall  of  clot  varies 
much  in  thickness  and  regularity,  and  the  ca^'ity  may  be  still  incom- 
plete, the  laminated  portion  of  the  clot  endowed  with  a  smooth 
surface  being  more  dome-shaped  in  outline  and  extent,  and  hardly 
reaching  the  actual  lips  of  the  arterial  wound. 

1  believe  this  process  occiu's  whenever  a  false  aneurysmal  sac 
is  eventually  developed,  since  such  cavities,  -whenever  they  ha\e 
existed  for  a  short  period,  are  i-oughly  or  symmetrically  sjiherical  in 
form,  while  the  original  space  occupied  by  the  arterial  hsematoma  is 
usually  extremely  irregular.  The  subclavian  aneurysm  depicted  in 
Fig.  47  is  a  good  example,  the  original  collection  of  blood  having 
occupied  the  whole  posterior  triangle  of  the  neck.  Again,  Avhen  the 
femoral  artery  is  wounded  by  a  bullet  traversing  Hunter's  canal,  the 
original  blood  effusion  travels  into  the  posterior  compartment  of  the 
thigh  through  the  opening  made  by  the  missile  in  the  adductor 
muscles.  Yet  the  cavity  of  a  traumatic  aneurysm  developed  in  this 
position  is  in  my  experience  practically  invariably  a  rounded  sac  limited 
to  the  anterior  aspect  of  the  adductor  muscles,  and  not  an  hour-glass 
sac  extending  from  the  front  to  the  back  of  the  limb.  The  great  mass 
of  primary  blood-clot  is  in  fact  quite  independent  of  the  eventual 
cavity  of  the  aneurysm. 

\V"hen  the  aneurysmal  sac  has  reached  its  fvdl  development,  a 
strong  fibrous  wall  is  formed,  from  which  the  overlying  structures 
may  be  readily  stripped,  the  interior  being  usually  strengthened  by  a 
variable  thickness  of  blood-clot  still  not  decolourized,  although  usually 
firm  and  tough  in  consistence.  When  the  sac  is  opened  in  the  course 
of  operation,  or  after  removal,  this  passive  clot  may  occupy  the  half 
or  more  of  the  potential  cavity  ;  its  presence  is  an  indication  of  the 
continuing  tendency  to  spontaneous  cure,  and  its  value  as  a  buffer 
interposed  between  the  full  force  of  the  blood-stream  and  the  fibrous 
boundary  of  the  cavity  is  considerable.  The  size  of  the  opening- 
connecting  the  lumen  of  the  Aessel  with  the  interior  of  the  sac 
obviously  depends  on  the  extent  of  the  original  injury,  but  it  is  remark- 
able in  some  instances  how  small  this  may  be  and  yet  allow  the  stoma 
to  retain  its  patency. 

One  peciiliarity  in  the  structure  of  these  sacs,  dependent  on  their 
mode  of  causation,  is  of  great  practical  importance.  I  refer  to  the 
fact  that  they  may  be  in  part  formed  from  neighbouring  structures. 
When  these  extraneous  elements  are  derived  from  adjacent  nerve 
trunks,  the  greatest  care  is  necessary  should  the  sac  require  to  be 


HAiMATOMA   AND   TRAUMATIC  FALSE  ANEURYSM     01 

excised.  A  partly  damaged  nerve  is  often  spread  out  widely  in  the 
wall  of  the  aneurysm,  and  unless  this  is  appreciated  an  important 
nerve  may  be  needlessly  sacrificed  by  the  operation. 

In  some  instances  the  original  large  common  sj)ace  oeeu[)icd  by 
the  hsematoma  becomes  loeulated,  and  the  circumferential  part  may 
become  cut  off.  This  "was  the  case  in  the  subclavian  aneurysm  depicted 
in  Fig.  47,  p.  182.  The  fluid  contained  in  the  superficial  locuhis  in 
the  posterior  triangle  had  already  become  decolourized  at  the  time  of 
operation,  and  was  quite  independent  of  the  deeper  aneurysmal 
cavity  beneath  the  remains  of  the  scalenus  anticus.  In  this  case  the 
loculus  was  a  development  of  much  importance,  since  the  thinning  of 
its  walls,  with  the  consequent  apparent  increase  in  size  in  the  swelling 
to  which  pulsation  continued  to  be  communicated,  was  regarded  as 
indicating  the  necessity  for  prompt  operation. 

This  mode  of  spontaneous  cure  may  be  even  more  direct.  Thus, 
in  an  officer  under  my  care  for  an  injury  to  the  nerve  trunks  in  the 
axilla  accompanied  by  extinction  of  the  radial  pulse  at  the  wrist, 
diu-ing  an  operation  for  the  relief  of  the  nerve  lesions  performed  by 
Colonel  Percy  Sargent,  a  spherical  sac  containing  two  ounces  of  straw- 
coloured  fluid  was  found  attached  to  the  proximal  termination  of 
the  severed  artery. 

A  somewhat  special  feature  of  false  traumatic  aneurysms  follow- 
ing gunshot  injuries  of  the  arteries  accompanying  injuries  to  the 
bones,  consists  in  the  deposition  of  bone  in  the  wall  of  the  sac  conse- 
quent on  the  diffusion  of  small  fragments  of  bone  and  freed  bone- 
cells  in  the  track  made  by  the  missile.  I  saw  one  instance  in  the 
case  of  a  femoral  aneurysm  operated  upon  by  Major  Littler  .Tones  in 
France.  A  still  more  striking  observation  of  a  bony  wall  has  been 
published  by  Major  Lawford  Knaggs,*  in  which  the  original  walls 
of  the  aneurysmal  sac  were  afforded  by  the  \q:)per  part  of  the  shaft 
of  the  humerus  itself,  the  aneurj^sm  later  becoming  diffused  into  the 
tissues  in  the  neighbourhood  of  the  shoulder.  The  specimen  is 
included  in  the  War  Collection  at  the  Royal  College  of  Surgeons. 

An  account  will  be  found  on  p.  116  of  an  arterio-venous  aneurysm 
of  the  innominate  vessels  in  which  the  sac  was  formed  b}^  an  old 
tuberculous  cavity  situated  in  the  apex  of  the  right  lung. 

Behaviour  of  Surrounding  Tissues.  —  It  must  not  be  assumed 
that  the  processes  of  diminution  of  size  and  solidification  of  the  walls 
of  the  aneurysmal  sac  depend  solely  on  the  absorption  and  contrac- 
tion of  the  primary  clot,  the  hollowing  out  of  the  interior,  and  the 
deposition    of   fibrinous    laminae    capable    of   later    de^'elopment    into 


*  British  Journal  of  Surgery,  1917,  vol.  v,  No.  18,  p.  243. 


-62       GUNSHOT    IX  J  CRIES    TO    THE    BLOOD-VESSELS 

fibrous  tissue.  Nor  do  these  things  alone  ensure  the  Hniitation  and 
final  solidity  of  the  aneurysm.  A  not  less  ini]jortant  part  is  played 
by  the  surrounding  tissues,  which  react  in  a  remarkable  manner  to 
the  stimulus  afforded  by  the  presence  of  the  blood-clot  in  their  midst. 
The  connective  tissue  of  the  vascular  cleft,  the  intermuscular  spa(;es, 
and  the  muscles  themselves,  become  infiltrated  with  serum  and  an 
abundance  of  leucocytes  destined  to  take  part  in  the  subsequent 
absorption  of  the  clot. 

A  considerable  part  of  the  mass  of  the  tumour  in  the  early  stages 
consists  of  this  siuTOunding  infiltration,  and  the  gradual  disappearance 
of  the  latter  and  of  the  cedema  accoimts  for  much  of  the  diminution 
of  the  ajDparent  size  of  the  tumoiu-.  It  is  this  induration  which  affords 
support  to  the  original  blood-clot,  and  tends  to  prevent  further  exten- 
sion of  the  aneurysm. 

The  occurrence  of  this  change  in  the  surrounding  tissues  is  also 
an  important  element  in  influencing  the  surgical  treatment  of  the 
aneurysm.  Even  the  process  of  exposure  and  delimitation  of  the 
sac  is  rendered  more  difficult  by  the  swollen,  indurated  condition  of 
the  connective  tissue,  and  the  separation  and  displacement  of  muscles 
is  interfered  with  by  the  firm  adhesion  between  them  and  their  sheath. 
Still  more  difficult  in  the  earlier  stages  is  the  freeing  of  the  blood- 
vessels themselves,  since  they  are  embedded  in  a  mass  of  tissue  like 
firm  bacon,  from  which  they  can  only  be  cleared  by  the  use  of  the 
knife.  It  is  this  infiltration  which  renders  operations  for  the  suture 
of  the  vessels  so  difficult  and  unsatisfactory  at  this  period,  because 
it  interferes  not  only  with  the  insertion  of  sutures,  which  readily  cut 
out,  but  also  renders  it  a  troublesome  task  to  free  the  ^'essels  suffici- 
ently to  approximate  the  ends  without  tension,  if  any  loss  of  substance 
has  occurred. 

Before  passing  on  to  a  consideration  of  the  signs  and  symptoms 
of  traumatic  aneurysm,  the  question  of  tardy  development  should 
receive  some  notice.  It  is  a  striking  fact  that  in  so  many  cases  the 
existence  of  an.  aneurysm  is  not  noted  until  days,  weeks,  or  even 
months  after  the  reception  of  the  original  injury.  No  doubt  in  many 
cases  this  is  due  to  the  small  size  of  the  sac,  and  to  imperfect  obserAa- 
tion  in  consequence  of  the  haste  with  which  many  ])atients  with  small 
Avounds  are  necessarily  evacuated.  Giving  due  weight  to  tliis  explana- 
tion, it  is  an  undoubted  fact  that  the  development  is  sometimes  a 
late  one,  and  mention  of  the  significance  of  incomplete  lesions  of  the 
vessels  in  this  relation  has  already  l)een  made  in  the  section  dealing 
with  contusion  of  the  vessels.  Another  explanation  of  the  tardy 
development  of  the  aneurysm,  however,  is  undoubtedly  to  be  found 
in  the  secondary  giving  way  of  an  originally  perforating  lesion  in 
which  the  process  of  spontaneous  healing  commences  and  eventually 


IhEMATOMA   AND  TRAUMATIC  FALSE  ANEURYSM     63 

fails.  The  most  striking  instances  are  afforded  by  the  cases  in  which 
the  original  hsematonia  has  been  evacuated  without  the  discovery  of 
any  bleeding  point,  and  the  wound  has  been  allowed  to  heal.  In 
connection  with  arteries,  even  of  the  magnitude  of  the  external  iliac, 
which  were  actually  exposed  during  the  process  of  clearing  out  the 
ha^matoma,  a  secondary  aneurysm  has  been  seen  to  develop  several 
days  later  while  the  patient  has  remained  under  observation. 

In  the  section  on  arterio-venous  communications,  an  instance  of 
early  and  apparently  permanent  disappearance  of  a  continuous 
murmur  will  be  foimd,  no  doubt  due  to  early  closure  of  an  opening  in 
the  vessels  ;  while  reference  to  Fig.  1  shows  how  nearly  an  opening 
in  the  arterial  wall  may  reach  complete  closure  and  j'^et  eventually 
give  rise  to  secondary  lucmorrhage,  or  under  other  conditions  to  a  late 
aneiu'ysm.  Fig.  21  also  furnishes  suggestive  information.  Here  the 
wound  is  closed  by  an  internal  cylindrical  clot  not  completely  obstruct- 
ing the  Inmen  of  the  vessel,  joined  by  a  narrow  band  to  a  larger  clot 
deposited  in  the  tissues  of  the  neck,  both  external  and  internal  clot 
being  most  likely  of  a  temporary  nature.  Another  not  uncommon 
occurrence  is  the  complete  extinction  of  local  pulsation  by  j^ressure 
exerted  on  the  main  vessel  owing  to  the  rapid  transformation  of  the 
effused  blood  into  a  firm  coagulum.  This  pressvire  may  suffice  to 
prevent  any  passage  of  blood  through  the  arterial  wound,  and  thus 
lead  to  the  extinction  of  the  bruit,  and  may  also  obstruct  the  circula- 
tion to  an  extent  involving  loss  of  vitality  of  the  limb  (see  Fig.  26, 
p.  72).  Yet  no  sign  of  an  aneurysm  will  be  present,  although  such 
may  readily  appear  at  a  later  date  when  the  absorption  of  the  original 
blood-clot  has  allowed  of  sufficient  dilatation  of  the  lumen  of  the 
vessel  for  the  restoration  of  the  circulation. 

Signs  and  Symptoms. — The  cardinal  local  signs  of  an  arterial 
htematoma  or  a  false  aneurysm— the  presence  of  a  localized  pulsating 
swelling,  the  pulsation  being  capable  of  control  by  pressiu'e  exerted 
on  the  artery  on  the  proximal  side,  need  no  further  description  ;  but 
a  few  additional  remarks  may  be  devoted  to  two  points — the 
characteristic  arterial  bruit,  and  the  effect  on  the  general  circulation. 
The  presence  of  this  bruit  indicates  an  incomplete  solution  of 
continuity,  that  is  to  say  a  wound  in  the  wall  of  the  artery  ;  it  is  in 
fact  a  sign  of  a  woiuided  artery  rather  than  of  an  aneurysm. 

The  systolic  murmiu's  vary  greatly  in  intensit}^,  depth  of  tone, 
and  musical  character.  As  a  rule,  during  the  first  few  days  they 
tend  to  be  shrill  and  loud,  and  are  audible  along  a  considerable  length 
of  the  vessel  on  the  peripheral  side  of  the  wound.  It  is  not  common 
for  the  bruit  to  be  conducted  for  any  material  distance  centrally,  and 
frequently  it  is  scarcely  audible  a  couple  of  inches  above  the  situation 
of  the  Avound.     The  character  of  the  bruit  depends  on  the  force  of 


04-       GUNSHOT    IX JURIES    TO    THE    BLOOD-VESSELS 

the  circulation,  and  upon  the  size  and  shape  of  the  opening  in  the 
vessel  and  the  deoree  of  irregularity  of  its  margins.  As  the  process 
of  rounding  off  the  ragged  margins  of  the  arterial  wound  progresses— 
a  si)ecies  of  incomplete  repair — the  murmur  tends  to  become  softer 
and  deeper  in  tone.  The  effect  of  diminution  in  size  and  increased 
regularity  of  surface  of  the  blood  cavity  may  also  be  a  factor  in  the 
production  of  this  change  of  character.  It  may  be  remarked  that 
at  the  same  ])eriod  the  heart's  action  is  commencing  to  recover  some- 
what from  the  disturbance  caused  by  the  wound  of  the  vessel  and 
the  resulting  interference  with  the  distal  circulation,  hence  the  jiulse 
is  less  rapid  and  forcible.  As  already  mentioned,  complete  coagulation 
of  the  effused  blood  of  the  hacmatoma  may  cause  a  temporary  or 
permanent  cessation  of  the  murmur  ;  in  the  latter  case  it  ma}^  be 
assumed  that  a  chance  of  closure  of  the  arterial  wound  exists.  In 
cases  Avhere  hard  clot  forms  early,  the  consequent  pressure  on  the 
arterial  wound  may  not  only  prevent  the  further  escape  of  blood,  but 
also  the  production  of  a  bruit.  In  these  a  nuu-mur  may  develop 
later  ;    hence  the  importance  of  repeated  examinations. 

Reference  to  the  fact  that  systolic  arterial  bruits  may  be  trans- 
mitted to  the  apex  of  the  heart  and  the  base  of  the  left  ventricle  has 
been  made  elsewhere  (p.  48). 

The  importance  of  auscultation  as  a  means  of  determining  the 
existence  of  a  patent  opening  in  the  wall  of  an  artery  cannot  be  too 
strongly  urged,  since  it  is  the  only  method  of  forming  a  certain 
diagnosis  in  some  cases,  for  instance  in  a  swollen  thigh  or  calf  in  which 
no  pulsation  is  detectable.  I  do  not  believe  that  the  fact  that  external 
pressure  on  the  vessel  may  give  rise  to  a  less  definite  murnnir  in  any 
waj^  invalidates  this  statement,  for  the  bruit  produced  by  pressure 
is  rare,  and  far  less  loud  and  definite  in  character. 

Progress  and  Complications — It  may  be  broadly  stated  that  the 
typical  course  of  an  arterial  ha?matoma  is  one  leading  to  contraction 
and  localization,  a  definite  false  aneurysm  being  the  commonest  final 
result.  In  the  most  fortunate  cases  the  aneurysm  itself  maj^  consoli- 
date spontaneously,  and  a  cure  by  natural  processes  occur.  Among 
the  large  arteries,  this  termination  is  most  commonly  met  with  in 
the  lower  few  inches  of  the  superficial  femoral  or  in  the  upper  third 
of  the  popliteal  arteries. 

Certain  complications,  however,  occur  with  a  considerable  degree 
of  frequency.  The  most  common  of  these  are  indications  of  pressure 
by  the  effused  blood  and  clot  on  neighboiu-ing  structures,  the 
development  of  peripheral  gangrene,  the  occiu-rence  of  secondary 
hirmorrhage,  the  detachment  of  emboli  from  the  thrombus,  and  rarely, 
the  sequence  of  inflammation  from  secondary  infection.  I  propose  to 
deal    with   these   complications   seriatim  ;     but   before   proceeding   to 


H/EMATOMA   AND   TRAUMATIC   FALSE  ANEURYSM    05 

their  consideration  it  should  be  pointed  ovit  that  they  occur  for  the 
most  part  during  the  stage  to  which  the  term  arterial  haimatoma  is 
strictl}^  appropriate  ;  that  is  to  say,  prior  to  the  definite  formation  oC 
the  smooth  secondary  ronnded  sac  which  has  been  already  describ(;d. 
When  this  sac  has  once  become  complete  and  of  moderate  thickness, 
the  condition  is  far  better  described  by  the  term  false  or  tranmatic 
aneurysm,  and  the  development  of  a  definite  fibrons-tissne  wall  may 
be  confidently  exj^ceted.  In  this  stage  complications  are  not  to  be 
greatly  feared — apart  from  the  obvious  fact  that  the  wall  may  be  of 
insufficient  strength  to  withstand  the  force  of  the  circulation  when 
active  movements  are  resumed,  and  the  aneurysm  may  consequently 
enlarge.  For  this  reason  it  appears  to  be  both  proper  and  convenient 
to  employ  the  terms  exactl}'^,  and  in  relation  to  the  stage  of  develop- 
ment which  the  condition  has  reached. 

Pressure  Symptoms, — The  most  common  pressure  symptom  is 
peripheral  oedema,  sometimes  increased  in  consequence  of  concomitant 
injury  to  the  vein.  Occasionally,  thrombosis  of  the  deep  veins  may 
give  rise  to  a  tense  persistent  swelling  of  the  limb,  but  this  is  not 
common,  and  in  many  instances  depends  on  infection  travelling  from 
the  wound.  Pain  from  pressure  on  neighbouring  nerves  is  not  an 
imcomrnon  symptom,  but  it  is  rarely  persistent,  and  diminishes  pari 
passu  with  the  localization  and  contraction  of  the  ha^matoma  or 
aneurysm.  Pain  coming  on  during  the  course  of  the  case  is  usually 
a  sign  of  extension  of  the  aneurysm.  It  must  be  borne  in  mind  also 
that  the  pain  may  depend  on  concomitant  injurj^  to  a  periiDheral 
nerve. 

The  most  serious  effect  of  pressure  is  that  dependent  on  obstruc- 
tion of  the  blood-stream  in  the  collateral  branches  of  the  arter}'',  since 
this  may  lead  to  peripheral  gangrene  of  the  limb,  not  an  uncommon 
occurrence  in  the  lower  extremity.  This  complication  is  more  fully 
discussed  in  the  sections  dealing  with  special  vessels. 

Secondary  haemorrhage  may  occur  at  two  periods,  either  in  the 
first  few  days,  or  after  the  lapse  of  a  week  or  ten  days.  The  earlier 
variety  is  the  less  important.  It  frequently  consists  in  little  more 
than  leakage  from  a  small  womid  during  the  early  progress  of  con- 
traction of  the  cavity  :  a  small  quantity  of  blood,  really  a  part  of 
the  original  effusion,  may  escape,  soil  the  dressing  for  two  or  three 
days,  and  then  entirely  cease.  It  is  important  to  appreciate  that 
such  leakages  are  not  an  indication  for  urgent  operative  measiires. 
and  that  they  are  not  to  be  regarded  in  the  same  light  as  small 
repeated  hsemorrhages  from  a  septic  wound. 

The  later  secondary  haemorrhage  is  vastly  more  dangerons.  It 
may  show  itself  in  two  forms,  either  a  rapid  extension  of  the  swelling 
in  the  limb,  or  as  external  haemorrhage.     It  is  rare  for  this  form  of 

5 


66        GUNSHOT    IXJUIUES    TO    THE    BLOOD-VESSELS 

haniiorrhage  to  arise  from  septic  infection  of  the  aneurysm  itself  ; 
it  ratlier  ap})cars  to  depend  on  a  defective  process  of  localization 
which  allows  some  part  of  the  limiting  bomidary  of  clot  to  give  way, 
often  as  a  result  of  infection  of  the  surrounding  tissues,  or  of  a  rise 
in  the  general  blood-pressure  accompanying  increased  activity,  and 
perhaps  of  free  movement  of  the  limb  on  the  part  of  the  patient. 

In  some  cases  it  appears  to  follow  the  giving  way  of  the  actual 
line  of  miion  of  small  aneurysmal  sacs,  such  as  are  depicted  in 
Fig.  22,  from  the  original  arterial  wound,  the  margins  of  which  have 
become  thinned,  smooth,  and  rounded  in  the  process  of  repair.  It 
may  be  repeated  that  the  margins  of  the  sac  joining  the  circumference 
of  the  wound  of  the  artery  are  the  most  tenuous  part  of  the  sac,  while 
the  dome  opposite  the  opening,  which  bears  the  full  force  of  the  blood- 
stream, is  the  thickest.  In  the  process  of  cicatrization  of  a  wound 
of  the  intestine  we  know  that  the  early  connecting  layer  of  hanph  is 
strongest  at  the  end  of  the  third  day,  and  that  during  the  next  foiu' 
or  five  days,  while  the  process  of  organization  of  the  lymph  into 
connective  tissue  is  taking  place,  the  union  is  percejDtiblj^  weaker  and 
less  able  to  bear  strain.  A  similar  weakening  of  the  line  of  union 
between  the  margins  of  the  sac  and  the  arterial  opening  may  be 
safely  assumed  to  take  place  while  the  same  process  of  conversion  of 
lymph  into  connective  tissue  is  progressing,  and  the  ease  with  which 
sacs  can  be  swept  off  the  vessel  confirms  this  assumption.  This  is 
the  dangeroTis  period,  which  should  be  regarded  as  demanding  complete 
rest  to  the  limb,  the  more  so  as  it  is  obvious  that  the  artery,  even  in 
its  more  fixed  condition  from  surrounding  infiltration  of  the  vascular 
cleft,  is  yet  a  more  freely  movable  structure  than  the  sac  when  active 
muscular  contractions  occur. 

Infection  of  the  boundary  of  blood-clot  itself  is  infrequent,  and 
even  an  extensive  cellulitis  involving  the  whole  limb  may  only  attack 
the  actual  wall  of  the  aneurysmal  sac  at  a  late  date  ;  yet  the  track  of 
the  missile  may  be  infected  and  remain  unrepaired,  and  thus  may 
not  only  Aveaken  the  support  afforded  to  the  clot  by  the  surroiuiding 
tissues  at  a  local  spot,  but  also  furnish  a  ready  path  for  the  escape 
of  the  blood. 

Late  secondary  ha?morrhages  are  extremely  dangerous  to  the 
vitality  of  the  limb,  whether  they  take  the  form  of  extensions  from 
the  blood  cavity  or  of  external  bleeding,  and  maj^  also  cause  grave 
risk  to  the  patient's  life. 

AVhen  secondary  hcTmorrhage  is  internal  and  causes  extension 
of  a  ha-matoma  or  traumatic  aneurysm,  its  occurrence  is  usually 
accom]3anied  by  severe  pain  coming  on  suddenly  and  tending  to 
augment,  and  on  local  examination  the  swelling  will  be  found  to 
have  increased  in  size  and  to  have  altered  in  outline  and  extent. 
The  accident  is  an  indication  for  prompt  surgical  intervention. 


HMMATOMA   AND   TRAUMATIC  FALSE  ANPAJHVSM     (>7 

The  question  of  arterial  thrombosis  and  emholism  lias  been  already 
dealt  with  under  the  heading  of  arterial  contusion,  and  will  be  again 
referred  to  in  the  special  sections. 

Secondary  Inflammation. — The  rarity  with  which  secondary 
inflammation  occurs  in  traumatic  aneurysm  affords  one  of  the  most 
striking  proofs  of  the  enormous  capability  of  the  blood,  even  when 
extravasated,  to  withstand  and  overcome  bacterial  infection.  Among 
the  whole  series  of  cases  I  met  with  personally,  only  two  instances  of 
death  resulting  from  acute  infection  of  the  blood-clot  occurred  ;  in 
both  the  infection  was  anaerobic  in  nature.  In  one  instance  the 
blood-clot  rapidly  broke  down  into  a  brown  fluid  offering  a  strong- 
resemblance  to  faeces,  and  the  patient  died  from  a  sudden  profuse 
secondary  haemorrhage.  It  occasionally  happens  also  that  a  false 
aneurysm  already  localized  becomes  hot  and  reddened  over  the 
surface,  and  this  must  be  regarded  as  an  indication  for  active  surgical 
treatment.  In  the  only  case  I  operated  upon  for  this  reason,  the 
aneurysmal  sac  itself  afforded  no  signs  of  inflammatory  change,  and 
primary  union  of  the  operation  wound  ensued. 

On  the  other  hand,  many  cases  came  under  observation,  especially 
in  the  thigh,  where  widespread  infection  of  the  surrounding  tissue 
had  led  to  suppuration  requiring  free  incisions  for  its  relief,  in  which 
an  existing  large  aneurysmal  sac  remained  unaffected.  In  one 
instance  anaerobic  infection  led  to  destruction  of  practically  the 
whole  musculature  of  the  thigh,  and  yet  a  very  large  aneurysmal 
sac  failed  to  give  way.  It  is  clear  that  a  strong  distinction  must 
be  drawn  between  infection  of  the  aneurysm  itself  and  infection  of 
the  surrounding  tissues. 

The  tendency  to  localization  and  slow  spread  of  infection  in 
large  masses  of  blood-clot  is  well  exemplified  by  the  phenomena 
observed  in  wounds  of  the  chest  giving  rise  to  a  ha-mothorax,  par- 
ticularly when  the  organisms  are  anaerobic.  In  many  of  these  cases 
repeated  exploratory  punctures  made  at  intervals,  and  in  different 
spots,  may  be  necessary  before  infection  can  be  definitely  proved 
(Elliott  and  Henry). 

The  risks  of  infection  are  greatest  during  the  arterial  ha^matoma 
stage,  when  the  collection  of  blood  is  large  and  the  boundary  layer  of 
clot  thin.  Under  these  conditions  the  effusion  of  blood  may  increase 
in  amount,  or  external  haemorrhage  may  occur.  Either  of  these 
accidents  may  necessitate  immediate  ligature  of  the  artery,  and  the 
cases  are  of  a  very  unsatisfactory  nature,  since  they  are  not  infre- 
quently followed  by  further  secondary  hsemorrhage,  often  not  from 
the  point  of  the  ligature  placed  upon  the  main  trunk,  but  from  wounded 
collateral  branches  exposed  in  the  original  wound  cavity  now  become 
septic,  which  failed  to  bleed  at  the  time  of  the  operation. 


08        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

Traumatic  .incunjsms  Developing  in  A)iiputatio)i  Stinnps.— 
Although  of  a  totally  different  nature,  ancuiysms  developing  iil)ove 
the  site  of  the  ligatiu'c  placed  upon  the  vessels  in  an  amputation 
dcsei'N'e  mention  in  this  place,  since  they  are  of  not  infrequent  occur- 
rence -when  the  woiuid  is  infected.  A  similarity,  moreover,  exists 
between  them  and  some  of  the  aneurysms  seen  to  develop  tardily  as 
a  result  of  the  secondary  giving  way  of  a  partial  lesion  of  an  artery 
in  a  septic  wound. 

In  the  early  stages  of  the  present  war  the  appearance  of  a  cherry- 
red  pulsating  tumoxu-  at  the  site  of  the  ligatured  main  vessel  in  an 
open  amputation  stump  was  a  not  imcommon  experience,  and  afforded 
an  indication  for  prompt  siu-gical  intervention  which  could  not  be 
disregarded.     The  condition  was,  in  fact,  the  precursor  of  a  secondary 


Ficj.  24. — Septic  aneurysm  of  the  femoral  artery,  which  formed  in  the  floor  of  an 
amputation  wound.  General  dilatation  of  the  softened  coats  of  the  artery  will  be 
observed  above  the  point  of  ligature.  Intramvual  extravasation  of  blood  has  occurred 
between  the  different  layers  of  the  arterial  wall,  and  at  the  under  svu:face  complete 
disintegration  and  necrosis  will  be  observed.  The  cavity  of  the  sac  has  become  shut 
off  from  the  lumen  of  the  artery,  and  is  occupied  by  recent  clot. 

hcTmorrhage  in  not  a  few  cases.  The  type  of  aneurysm  is  so  well 
known  in  civil  practice,  either  in  similar  circumstances  or  when 
arising  in  connection  with  the  arrest  of  a  septic  embolus  in  the 
artery,  that  it  is  unnecessary  to  devote  further  attention  to  it  here. 
Fig.  24  illustrates  a  good  example,  but  in  this  case  the  sac  was  buried 
in  the  tissues  of  the  partly-united  flaps.  The  limb  from  which  it  was 
removed  Avas  re-amputated  by  Colonel  Gordon  Watson,  to  whom  I 
i  m  indebted  for  allowing  me  to  have  the  drawing  made. 

ARTERIO-VENOUS     HEMATOMA      AND      ANEURYSM. 

In  the  series  of  cases  upon  which  this  essay  is  founded,  the  arterio- 
Acuous  aneurysms  form  the  majority.  In  the  earlier  part  of  the  war, 
while  ])ullet  wounds  still  formed  a  large  proportion  of  all  the  injuries 


RJEMATOMA   AND   TRAUMATIC  FALSE  AN  FAIRY  SM     09 

met  with,  the  arterial  hcTmatoma  was  the  more  common  ;  this 
depended  on  the  more  sharply  defined  nature  of  the  wound  caused 
by  the  bullet  when  travelling  accurately.  With  the  advent  ol"  a  orcater 
number  of  injuries  caused  by  fragments  of  shells,  arterio-venous  lesions 
have  increased  in  proportional  frequency. 


Distribution  and  Nature  of  272  Traumatic  Aneurysms. 


Artery 

Cases 

Arterial 

Arterio- 
venous 

Aneurysmal 
varix 

Carotid  ' "    .  . 

Subclavian  .  . 

Axillary 

Brachial 

Femoral 

Popliteal 

57 
24 
41 
22 
87 
41 

10 
13 
24 

17 
36 
20 

29 
11 
8 
1 
34 
17 

18 

9 

4 

17 

4 

Totals      .  . 

2  72               120 

100 

52 

The  aneurysmal  sac  in  the  mixed  injury  is  to  be  regarded  as 
purely  arterial  in  nature,  and  is  always  directly  connected  with  the 
wound  in  the  artery.  The  vein  plays  but  a  secondary  part,  although, 
as  a  result  of  the  local  dilatation  which  always  takes  place,  it  furnishes 
a  considerable  proportion  of  the  whole  bulk  of  the  tumour. 


Fig.  25. — A,  Simple  aneurysmal  varix.  B,  Arterio-venous  aneurj'sm  ; 
sac  interposed.  C.  Arterial  aneurysm  combined  with  anevu-ysmal  varix.  D, 
Arterial  and  arterio-venous  sac.  E,  Arterio-venous  sac  with  common  opening 
of  communication  with  artery  and  veiia.  F,  Arterio-venous  sac  with  separate 
openings  of  commiuiication  with  artery  and  vein. 


The  diagrams  {Fig.  25),  representing  transverse  sections  through 
the  aneurysms,  illustrate  various  ways  in  w^hich  the  arterial  sac  may 
be  arranged.  A  is  a  pure  aneurysmal  varix  ;  in  B  the  arterial  sac 
is  interposed  between  the  artery  and  vein — in  such  cases  the  missile 


70        GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

has  probably  })asscd  between  the  two  vessels,  and  effected  a  lateral 
wound  in  the  opposing  side  of  either  ;  in  D  an  arterial  sac  has  been 
formed  in  connection  Avith  the  wound  on  either  side  of  the  artery, 
and  thus  a  sac  springs  from  the  free  side  of  the  vessel  as  w^ell  as  from 
that  opposed  to  the  vein.  This  arrangement  is  the  result  of  the 
jjassage  of  a  missile  which  has  traversed  both  vessels,  the  woimd  on 
the  free  aspect  of  the  vein  having  closed  spontaneously.  In  C  the 
sac  springs  from  the  free  side  of  the  artery,  while  a  direct  communica- 
tion has  been  established  between  the  artery  and  vein.  This  arrange- 
ment also  results  from  a  traversing  injury,  and  we  have  the  conditions 
of  an  arterial  aneurysm  and  an  aneurysmal  varix  combined.  In  E 
and  F  the  missile  has  crossed  the  vessels  either  on  the  suiDcrficial  or 
(more  often)  their  deep  aspect — in  E  a  common  opening  of  the  two 
vessels  communicates  with  a  sac  situated  in  the  angle  of  luiion,  in 
F  the  sac  has  a  separate  opening  for  each  vessel.  This  form  of  sac 
I  have  seen  both  in  the  case  of  the  carotid  and  of  the  femoral  vessels 
lying  on  their  deep  aspect. 

When  the  vein  has  suffered  complete  severance,  the  peripheral 
end  may  heal  and  close  while  the  central  end  remains  patent,  and 
in  these  circumstances  the  stream  of  blood  from  the  artery  pours 
directly  into  the  open  end  of  the  vein.  In  one  case  of  carotid  arterio- 
venous aneurysm  of  this  nature  upon  which  I  operated,  a  piece  of 
shell  the  size  of  the  top  of  my  forefinger  was  retained  within  the  sac, 
and  probably  afforded  an  explanation  of  the  arrangement.  Reference 
to  Fig.  1,  p.  2,  will  show  how  such  a  condition  might  readily  be 
established. 

In  the  ease  of  some  vessels,  e.g.,  carotid,  subclavian,  etc.,  the 
perforation  may  not  only  implicate  the  corresponding  artery  and 
vein,  but  also  such  structures  as  a  nerve  or  ixiuscle  situated  between 
them.  Examples  of  the  part  which  may  be  taken  by  the  vagus  will 
be  found  in  the  section  devoted  to  carotid  aneurysms,  and  the 
classical  observation  by  Matas  of  a  subclavian  arterio-venous  anasto- 
mosis in  which  the  anterior  scalene  muscle  took  a  part  may  be  again 
alluded  to. 

Extended  experience  has  made  me  doubtful  whether  an  arterio- 
venous aneurysm  ever  develops  as  a  result  of  complete  severance  of 
the  two  vessels.  Such  aneurysms  have  been  described  ;  but  I  think 
this  was  before  common  knowledge  of  the  behaviour  of  a  vessel  which 
has  suffered  division  of  more  than  three-quarters  of  its  circmiiference 
existed  ;  also  of  the  difficulty  which  may  present  itself  of  recognizing 
the  remaining  strand  of  the  wall  of  the  vessel,  and  of  the  thorough 
w^ay  in  which  such  strands  become  incorporated  as  an  integral  portion 
of  the  wall  of  the  sac  of  the  aneurysm. 

I  have  never  seen  an  aneurysmal  sac  formed  in  communication 


HEMATOMA   AND   TRAUMATIC  FALSE  ANEURYSM     71 

with  an  opening  on  the  free  side  of  the  vein.  In  every  instance 
of  traversing  perforation  of  the  vessels  whieh  I  have  examined,  the 
opening  on  the  free  side  of  the  vein  had  eieatrized.  If  the  mode 
of  development  of  a  traumatic  false  aneurysm  already  described 
be  correct,  it  is  very  difficult  to  believe  that  a  sac  could  be  formed 
as  a  result  of  the  pressure  of  a  current  of  blood  from  the  artery 
crossing  the  lumen  of  the  vein.  Other  arguments  bearing  in  the  same 
direction  may  be  cited,  such  as  the  constancy  with  which  dilatation 
of  the  lumen  of  the  vein  is  met  with,  and  the  well-known  ease  and 
regularity  with  whieh  wounds  of  the  veins  undergo  spontaneous 
closure. 

I  am  also  inclined  to  attribute  the  maintenance  of  the  peripheral 
pulse  after  'complete  severance'  of  the  vessels  which  has  been 
described,  to  the  persistence  of  a  narrow  strand  of  the  arterial  wall, 
which  in  some  measure  keeps  the  separated  openings  in  the  vessel  in 
line,  and  aids  in  directing  the  current  of  blood.  It  appears  evident  that 
the  very  great  majority,  if  not  all,  of  arterio-venous  aneurysms  result 
from  either  lateral  wounds,  or  traversing  perforations  of  the  vessels. 

Some  interesting  clinical  differences  are  observed  between  aneu- 
rysms of  the  arterio-venous  and  the  purely  arterial  variety. 

A  striking  feature  is  seen  in  the  delay  whieh  often  occurs  before 
the  true  character  of  the  lesion  can  be  correctly  determined.  It  is 
a  remarkable  fact  that  while  the  aneurysmal  varix  is  usually  an 
immediate  development,  it  is  sometimes  days  or  even  weeks  before 
an  arterio-venous  aneurysm  can  be  diagnosed  with  certainty. 

Fig.  26  affords  a  good  example  of  an  instance  in  which  delay 
occurred  in  the  possibility  of  making  a  diagnosis.  The  conditions 
for  the  formation  of  an  arterio-venous  aneurysm  are  present  and 
favourable,  but  sufficient  time  had  not  elapsed  for  the  process  to 
be  completed,  or  even  actually  commenced.  The  blood  in  the 
primary  htematoma,  as  is  often  the  case,  had  coagulated  into  a  large 
firm  clot  in  which  no  cavity  existed.  The  clot  exercised  pressure, 
not  only  on  the  main  trunk,  but  also  on  the  collateral  branches 
of  the  wounded  vessel,  and  gangrene  of  the  leg  resulted,  necessi- 
tating an  amputation. 

A  second  cause  for  delay  in  the  development  of  arterio-venous 
aneurysms  is  found  in  a  temporary  closure  of  the  openings  or  opening 
in  the  vein  by  a  thrombus.  Occluding  thrombi  are  naturally  far 
more  common  in  veins  than  in  arteries,  by  reason  of  the  lesser  force 
of  the  venous  circulation.  It  may  also  happen  that  the  opening 
into  the  vein  is  occluded  by  a  foreign  body;  thiiS,  in  one  instance 
operation  on  an  apparently  pure  arterial  injury  disclosed  a  wounded 
artery,  with  the  piece  of  shrapnel  case  which  had  caused  it  filling 
and  controlling  the  contiguous  opening  in  the  vein. 


T2        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

The  clinical  evidence  in  support  of  the  comparatively  late  develap- 
nient  of  arterio-venons  sacs  is  equally  strong.  The  first  indication  of 
the  possible  formation  of  an  aneurysm  may  be  the  presence  of  the 
characteristic  systolic  arterial  bruit,  a  sign  which  can  be  detected 
prior  to  the  appearance  of  either  swelling  or  pulsation.  In  many 
cases  the  svstolie  bruit  becomes  softer  as  the  margins  of  the  opening 


Fig.     26. — A\'oDNDED     Popliteal 

Artery     and     Vein,    followed 

BY  Gangrene  of  the  Leg. 

The  woiuid  in  the  artery  involves 
nearly  half  its  calibre  and  gapes  widely  ; 
the  margins  of  the  opening  are  com- 
paratively smooth.  The  limb  ^^•as  am- 
putated on  the  fifth  day. 

A  characteristic  traversing  perfora- 
tion of  the  vein  is  shown,  the  shape 
of  the  openings  being  irregularly  cir- 
cvilar. 

The  extravasatod  blood  from  these 
wounds  had  clotted  firmly  en  masse  ; 
no  murmur  was  audible  in  the  swelling 
formed  by  the  clot.  Gangrene  of  the 
leg  and  foot  was  definite  on  the  fourth 
day. 

Under  the  care  of 
Capt.    West,  I. M.S. 


in  the  arterial  wall  become  smoother  in  the  process  of  repair,  and  then 
is  replaced  by  the  characteristic  continuous  murmur  of  the  arterio- 
venous communication,  and  a  bubbling  thrill  becomes  palpable. 
This  sequence  of  events  may  occupy  a  few  days,  or  sometimes  as  much 
as  a  couple  of  Aveeks,  and  may  often  be  observed. 

In  arterio- venous  aneurysms  the  tumoiu-  and  extent  of  pulsation 
which  may  be  present  in  no  way  indicate  the  size  and  extent  of  the 


HEMATOMA  AND  TRAUMATIC  FALSE  ANEURYSM     1?> 

actual  sac,  since  both  may  be  exaggerated  by  the  existing  dilatation 
of  the  vein.  Lastly,  the  aneurysms  do  not  tend  to  reach  so  large  a 
size  or  acquire  so  firm  a  walled  sac,  neither  are  they  so  likely  to  give 
rise  to  trouble  from  secondary  ha;morrhage  or  extension  of  the  sac. 
The  explanation  of  these  peculiarities  of  the  arterio-venous  aneurysm 
is  obvious  :  the  presence  of  the  open  vein  furnishes  a  species  of  safety- 
valve;  hence  the  pressure  exerted  on  the  walls  of  the  sac  is  less  severe 
than  is  the  case  with  pure  arterial  aneurysms.  This  fact  is  demon- 
strated clinically  by  the  fact  that  a  large  proportion  of  the  arterial 
variety  need  to  be  operated  upon  as  an  urgent  measure,  while  a  much 
larger  number  of  the  arterio-venous  are  able  to  be  temporized  with, 
and  transferred  safely  to  base  hospitals  for  treatment  in  England  or 
elsewhere. 

Complications  attending  87  Femoral  Arterial  and 
Arterio-venous  Aneurysms  respectively. 


Arterial 

Arterio- 
venous 

Aneurysmal 
varix 

Secondary  haemorrhage 

Extension 

Pre-operative  gangrene 

Post-operative  gangrene     .  . 

Gas  gangrene 

Inflammation 

Amputation  .  . 

Death             

4 
6 
3 
2 
2 
2 
3 
6 

3 

1 
4 
2 
1 
0 
3 
5 

0 
0 
0 
0 
0 
0 
0 
0 

Sent  home  without  operation 

8 

15 

17 

Totals 

36 

34 

17 

Signs  of  Arterio-venous  Aneurysm. — Special  observation  of  a 
large  number  of  cases  has  revealed  some  points  of  interest  with  regard 
to  the  character  of  the  murmurs  which  accompany  the  condition. 
The  fact  that  the  systolic  element  of  the  bruit  may  be  audible  first 
has  already  been  dwelt  upon.  It  remains  to  say  that  the  characters 
of  this  may  vary  considerably  :  it  may  be  soft  and  musical,  or  harsh 
in  sound.  Sometimes  it  acquires  a  'slamming'  character,  simulating 
in  an  exaggerated  degree  the  so-called  'pistol  shot'  murmur  heard  in 
valvular  disease  over  the  aortic  orifice  of  the  heart.  Such  murmurs 
are  associated  with  a  highly  excitable  state  of  the  general  circulation 
and  apparent  cardiac  dilatation,  conditions  which  in  some  degree 
accompany  every  traumatic  aneurysm  in  its  earlier  stages.  The 
increased  rapidity  of  the  pulse  tends  to  settle  doAvn,   but  does  not 


74       GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

always  subside  at  once  even  when  the  Avoinid  in  the  vessels  has  been 
dealt  with  by  operation. 

The  loud"  systohc  murmur  is  conducted  widely  peripherally,  and 
to  a  nuich  less  extent  centrally  ;  but  in  exceptional  cases  it  may  be 
transmitted  centrally  even  from  the  lower  extremity  to  the  heart. 
The  diastolic  roar  is  conducted  in  either  direction,  but,  as  might  be 
expected,  more  freely  in  a  central  direction  in  the  vein.  It  is  always 
loudly  audible  in  the  opposite  side  of  the  neck  in  cervical  aneurysms, 
and  when  the  aneurysm  is  at  the  root  of  the  neck,  may  be  audible 
over  the  whole  cardiac  area,  quite  separately  from  the  normal  valvular 
sounds  of  the  heart  itself. 

In  some  instances  the  murmur  may  be  conducted  by  the  whole 
mass  of  the  tissues  of  the  limb,  and  be  audible  wherever  the  stethoscope 
is  placed  upon  the  surface  ;  occasionally  the  sound  may  be  heard 
even  when  the  ear  is  in  neither  direct  nor  indirect  contact  with  the 
limb.  These  phenomena  are  more  common  in  the  lower  limb,  and 
in  the  early  or  arterial  hfematoma  stage  when  a  large  collection  of 
effused  blood  is  present. 

As  a  rule,  the  murmur  is  only  conducted  along  the  actual  line 
of  the  peripheral  vessels  ;  and  the  presence  of  the  bruit,  either  at  the 
wrist  or  the  ankle,  is  a  valuable  indication  of  the  persistence  of  a 
column  of  blood  in  the  vessels  when  the  amount  is  of  insufficient 
volume  and  force  to  be  palpable  as  a  pulse. 

The  height  of  pitch  of  the  murmur  is  a  valuable  guide  to  the 
exact  site  of  the  arterio-venous  communication.  It  is  highest  and 
loudest  immediately  over  this  spot,  the  tones  gradually  softening  and 
deepening  in  either  the  upward  or  dowuAvard  direction  as  tlie 
stethoscope  is  moved  along  the  lengthening  column  of  blood  in  the 
course  of  the  vessels. 

Bubbling  Thrill. — What  has  been  said  regarding  the  tardy 
development  of  the  arterio-venous  murmur  holds  equally  good  for 
that  of  the  thrill.  It  may  not,  as  is  usually  the  case  with  aneurysmal 
varices,  be  palpable  in  the  earliest  stage,  while  it  tends  to  become 
stronger  and  more  readily  palpable  during  the  first  few  days.  Thus, 
while  it  may  be  of  the  feeble  '  faradic-current '  type  when  first 
detected,  with  the  reappearance  or  strengthening  of  the  peripheral 
pulse  it  may  become  strong  and  easily  felt. 

The  thrill  is  often  widely  diffused,  and  is  not  a  valuable  localizing 
sign  of  the  exact  position  of  the  opening  of  communication.  In  this 
respect  the  loudness  and  height  of  pitch  of  the  murmur  is  more 
reliable.  In  many  eases  the  commimication  of  the  thrill  consequent 
on  a  wound  of  a  branch  of  the  main  vein  may  give  rise  to  a  quite 
erroneous  diagnosis  if  depended  upon  alone.  This  is  a  marked  feature 
in  woimds  of  the  circumflex  vessels  of  the  thigh — in  these  the  thrill 


HA^MATOMA   AND  TRAUMATIC  FALSE  ANEURYSM    75 

is  often  strong  and  most  easily  detected  in  the  femoral  vein  ;  and  the 
same  feature  is  not  uncommon  in  connection  with  wounds  of  the 
branches  joining  the  internal  jugular  vein  in  the  neck. 

When  the  aneurysms  are  of  long  standing  there  is  no  doubt 
chat  the  vessels,  both  artery  and  vein,  tend  to  enlarge  and  become 
thickened  on  the  proximal  side  of  the  obstruction,  while  varicosity 
of  the  veins  and  swelling  of  the  peripheral  part  of  the  limb  develop. 
These  sequeltx;  are  common  in  the  lower  extremity,  far  less  so  in  the 
upper.  In  either  situation  a  previous  disposition  to  enlargement  or 
varicosity  of  the  veins  may  influence  adversely  the  degree  to  which 
these  troubles  attain.  In  the  earlier  stages,  and  especially  while  the 
patient  is  still  confined  to  his  bed,  little  evidence  of  venous  obstruction 
is  present  beyond  some  general  swelling  of  the  limb.  The  swelling- 
may  be  more  marked  if  progressing  thrombosis  occurs,  but  this 
accident  is  uncommon  unless  it  starts  in  connection  with  septic 
infection  of  the  main  wound  of  the  soft  parts. 

There  is  no  essential  difference  of  nature  between  the  sacs  and 
those  of  purely  arterial  origin,  and  they  are  liable  to  the  same  process 
of  gradual  contraction  and  regularization  ;  but  progress  to  spontaneous 
consolidation  and  cure  is  rarely  or  never  seen.  Resumption  of  active 
life  on  the  part  of  the  patient  is  therefore  liable  to  be  followed  by 
increase  in  size  of  the  sac,  and  the  development  of  venous  obstruction, 
or  other  pressure  symptoms. 

The  sacs  are  liable  to  the  same  early  complications  as  the  arterial 
variety,  but,  as  has  been  already  explained,  these  are  of  less  frequent 
occurrence. 

ANEURYSMAL     VARIX. 

The  immediate  establishment  of  a  direct  lateral  anastomosis 
between  a  contiguous  artery  and  vein  is  the  most  remarkable  of  any 
results  of  gunshot  injury  to  the  vessels.  Its  occurrence  is  in  great 
part  dependent  on  two  points  in  the  anatomical  arrangement  of  the 
two  vessels  implicated,  viz.,  contiguity  and  parallelism  of  course ; 
and  the  most  typical  examples  are  seen  when  the  missile  passes 
between  the  artery  and  vein,  causing  a  lateral  wound  in  both.  Fig.  27 
depicts  an  aneurysmal  varix  of  this  class  ;  it  will  be  seen  that  a  trans- 
verse slit  wound  has  been  caused  in  the  artery,  and  a  roughly  stellate 
one  in  the  vein.  Examination  of  the  carotid  sheath  and  vascidar 
cleft  showed  that  no  gross  bleeding  had  taken  place  into  the  tissues, 
and  that  direct  primarj^  adhesion  between  the  two  vessels  had 
resulted.  A  better  anastomosis  could  not  have  been  established  by 
the  most  skilful  surgical  operation.  A  similar  observation  was  made 
in  a  case  of  femoral  varix  included  in  Surgeon-General  Ste^'enson's 
Report  on  the  surgical  cases  noted  in  the  South  African  War,  and  the 


76        GUXSHOT    INJURIES    TO    THE    BLOOD-]' ESSELS 

frequency  witli  which  such  primary  adhesion  takes  ])laec  Avithoiit  the 
occurrence  of  lianiori'hage  is  now  common  knowledge. 

Fig.  28,  built  up  from  a  scries  of  sections  of  the  point  of  junction 
of  the  vessels  in  a  femoral  aneurysmal  varix  of  ten  days'  standing, 
for  which  I  am  indebted  to  the  aid  of  Captain  Bashford,  furnishes 


ARTERY  '^^"' 

Fig.  27. — Aneurysmal  Varix  of  the  Left  Common  Carotid  Artery  and  Internal 

JuGTJLAR  Vein. 
A  simple  transverse  lateral  slit  is  seen  from  the  interior  of  the  artery,  and  a  roughly 
stellate  opening  from  the  interior  of  the  vein.  No  blood  had  been  extravasated  into 
the  vascular  cleft,  and  adhesion  between  the  two  vessels  was  immediate  and  complete. 
The  typical  signs  of  a  carotid  aneurysmal  varix  were  present.  The  patient  died 
on  the  seventh  day  froiri  concurrent  injuries  to  the  head.  Under  the  care  of  Major 
Parsons. 


the  finer  details  of  the  mode  of  union.  The  illustration  shows  that 
the  actual  bond  of  tmion  consists  in  part  of  displaced  fragments  oi' 
tissue  originating  from  the  various  elements  of  the  walls  of  the  vessels, 
in  part  of  organizing  blood-clot.  The  significance  of  the  small  tongue 
of  arterial  advcntitia  projecting  into  the  blood-stream  has  been  alluded 


HJEMATOMA  AND   TRAUMATIC  FALSE  ANEURYSM     77 

to  in  connection  with  the  factors  involved  in  determining  the  character 
of  individual  local  vascular  murmurs.  At  a  later  date  of  cicatrization 
much  of  the  irregularity  of  surface  depicted  would  have  disappeared. 


■K^v  ^ 


Displaced  tissue. 


Artery. 


Fig.  28. — Aneurysmal  Varix  of  Femoral  Artery  and  Vein. 

Semi-diagrammatic  view  of  the  angle  of  junction  of  the  artery  and  vein.  Union 
has  been  effected  by  means  of  an  intervening  portion  of  displaced  tissue  derived  from 
the  adventitia  and  muscular  coats  of  the  artery,  and  it  contains  also  a  portion  of  the 
internal  elastic  lamina.  The  displaced  tissue  is  united  to  the  wall  of  the  artery  partly 
by  continuity  and  j)artly  by  blood-clot,  but  to  the  wall  of  the  vein  by  blood-clot  only. 

Captain  Bashford. 

A,  Internal  elastic  lamina  of  vein.  B,  Deep  clot  in  rent  in  vein  continuous 
with'^^the  wound  and  containing  portions  of  internal  elastic  lamina.  C.  Disorganized 
muscular  coat  of  vein.  D.  Endothelium  covering  organized  clot  adherent  to  vein 
wall.  E,  Spaces  lined  by  endothelivun  at  original  level  of  endothelium  of  vein.  F, 
Everted  wall  of  vein,  muscular  coat  and  adventitia  covered  with  organized  clot  and 
lined  with  endothelium.  G,  Displaced  internal  elastic  lamina,  probably  of  the  artery. 
H,  Everted  external  elastic  lamina  and  adventitia  of  artery  :  this  projecting  point 
is  the  only  surface  not  covered  by  endothelium  ;  this  fact,  and  the  fibrin  clot  and  leuco- 
cytes situated  between  it  and  the  artery,  suggest  that  it  may  have  vibrated  in  the  blood- 
stream. I.  Retracted  internal  elastic  lamina  of  artery.  J,  Proliferated  endothelium 
of  artery,  the  proliferation  being  slight  compared  with  that  of  the  vein.  K.  Increased 
thickness  of  sub-endothelial  tissue.  L,  Muscular  coat,  disorganized  clot  only  at  site  of 
injury  and  becoming  normal  at  extreme  right.  The  muscle  fibres  throughout  appear 
somewhat  swollen,  and  there  is  everywhere  a  slight  infiltration  of  red  blood-corpuscles. 
M,  Adventitia  of  artery.  N,  DisjDlaced  portions  of  muscular  coat  of  artery.  O, 
Displaced  portions  of  small  nerve.  P,  Part  of  the  track  of  the  missile,  lined  tln-ough- 
ont  by  endothelium  lying  either  on  blood-clot,  or  directly  on  the  walls  of  the  vessel. 
In  the  mid-point  of  the  left-hand  side  of  the  track,  much  proliferation  of  endothelium. 

We  are  well  aware,  moreover,  that  the  general  tendency  is  for  these 
openings  to  contract  in  size,  and  even  to  close  spontaneously.   I  have 


78        GUNSHOT    IXJIHIES    TO    THE    BLOOD-VESSELS 

obscrvfd  this  latter  result  in  its  various  stages  in  two  instances  of 
carotid  arterio-venous  aneiu'ysm,  in  which  primary  consolidation  of 
the  sac  was  induced  by  proximal  ligatiu'c  of  the  common  carotid 
artery.  In  both  these  cases  the  venous  roar  was  reduced  or  disappeared 
after  the  operation,  only  to  return  to  its  original  strength  in  a  few  days. 
In  both  it  subsequently  gradually  decreased  in  strength,  and  after  in- 
tervals of  fifteen  and  twenty  months  respectively,  finally  disappeared. 
One  of  the  patients  served  actively  diu'ing  the  first  two  years  of  the 
present  Avar,  fourteen  years  after  the  date  of  his  operation.  I  have 
also  had  the  opportunity  of  observing  continuously  the  slow  contrac- 
tion and  eventual  complete  closure  of  an  arterio-venous  eommimica- 
tion  between  the  innominate  artery  and  vein,  the  j^roeess  extending 
over  a  period  of  five  years.*  A  similar  result,  with  pathological  details 
from  the  specimen  obtained  after  death,  has  been  recorded  by  Sir 
W.  Oslerf  in  a  case  of  axillary  varix  {Fig.  29). 

Experimental  arterio-venous  anastomoses  established  in  animals 
have  also  demonstrated  the  tendency  for  spontaneous  closure  to 
follow,  and  this  tendency  has  been  further  illustrated  by  the  experience 
gained  in  the  treatment  of  senile  gangrene  by  establishing  communica- 
tions between  the  arteries  and  veins. 

The  direct  nature  of  the  adhesion  between  the  vessels  sufficiently 
explains  the  fact  that  the  signs  of  an  aneurysmal  varix  are  developed 
immediately  after  the  reception  of  the  injury  in  the  great  majority  of 
instances.  The  only  secondary  change  which  develops  in  these 
circumstances  is  a  dilatation  of  the  lumen  of  the  vein,  with  thickening 
of  its  wall.  The  dilatation  may  be  sufficient  to  create  suspicion  as  to 
the  presence  of  an  aneurysmal  sac,  the  more  so  as  the  arterial  pulsa- 
tion is  communicated  to  the  enlarged  vein.  Aneurysmal  varices  some- 
times follow  wounds  in  which  such  accurate  primary  adaptation  of 
the  two  vessels  is  impossible  ;  in  such  instances  the  develoj^naent  of 
thrill  and  murmiu*  may  be  a  later  event.  In  these  circmnstances 
it  must  be  supposed  either  that  the  union  and  cicatrization  has  been 
effected  under  a  larger  mass  of  blood-clot,  such  as  has  been  described 
as  present  at  a  certain  stage  in  the  development  of  the  traumatic 
aneurysms,  but  in  which  no  secondary  cavity  has  been  formed  ;  or 
that  a  temporary  venous  thrombosis  occurred.  A  case  of  injury  to 
the  innominate  vessels,  in  which  a  thrill  and  double  murmur  developed 
at  a  late  period,  is  quoted  on  p.  117.  Here  no  evidence  of  an  aneurys- 
mal sac  could  be  detected,  but  as  the  lesion  was  within  the  chest, 
one  cannot  be  certain  on  this  point. 


*  Journal  of  the  Royal  Army  Medical  Corps,  1905,  vol.  iv,  .June,  p.  746. 
■f  Lancet,   1913,   vol.    ii,    p.    1248. 


HEMATOMA  AND  TRAUMATIC  FALSE  ANEURYSM     7f> 

An  extended  experience  of  cases  of  aneurysmal  varix  has  led  me 
to  doubt,  however,  whether  this  condition  often  develops  primarily 
except  in  instances  in  which  the  vessels  are  wounded  by  a  missile 
which  passes  between  the  artery  and  the  vein  implicated,  or  in  those 
instances  of  perforation  of  both  vessels  from  side   to   side   in  which 


'MA— _4^\    \  \  y ^ — r^^ 


Fig.  29. — S.A.M.,  Scalenus  antious  muscle.  A. A.,  Axillary  artery.  T.A.A., 
Thoracico-acromial  artery.  CV-,  Cephalic  vein.  A-V.,  Axillary  vein.  I.M.A.' 
Internal   mammary   artery.      B-P.,    Brachial   plexus.     Sir   W.   Osier. 

the  two  outer  openings  cicatrize  while  those  in  the  contiguous  sides 
of  the  vessels  adhere. 

The  two  examples  of  the  conversion  of  arterio-venous  aneurysms 
into  pure  varices  as  a  result  of  ligature  of  the  artery  alluded  to  above, 
make  it  reasonable  to  suppose  that  spontaneous  consolidation  of  an 
aneurysmal  sac  would  also  be  followed  by  a  like  result. 


Si)       GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

A.  case  such  as  that  depicted  in  Fig.  30  offered  a  considerable 
field  for  specidation ;  here  no  aneurysmal  sac  had  developed  at 
the  end  of  the  eighth  day,  neither  was  there  any  collection  of  blood 


ART^Ry 


VEIN 


Fifj.  30. — Wounds  of  the  Left  Common  Carotid  Artery  and  Internal 
Jugular  Vein.      Twice  the  natural  size. 

A  traversing  perforation  of  the  vein  is  seen,  with  fairly  symmetrical  openings, 
■and  a  lateral  transverse  wound  of  the  artery.  Between  the  vessels  the  left  vagus 
is  shown,  greatly  enlarged  by  the  extravasation  of  blood  into  its  sheath. 

The  signs  were  those  of  a  typical  carotid  aneurysmal  \"arix  ;  no  symptoms 
attributable  to  the  vagal  injury  were  noted  beyond  hoarseness  of  voice  from  abductor 
paralysis.  The  patient  died  from  secondary  luvmorrhage.  Under  the  charge  of  Captain 
Oliver. 


in  connection  with  the  "wotnids  in  the  vessels  except  that  enclosed  in 
the  sheath  of  the  left  vagus.  The  track  leading  from  the  arterial 
wound  into  the  larynx  had  remained  narrow — so  narroA\,  in  fact,  that 


H  JEM  ATOM  A  AND  TRAUMATIC  FALSE  ANEURYSM     si 

it  was  only  discovered  by  a  very  careful  search  when  the  specimen 
was  dissected.  It  is  possible  that  a  permanent  indirect  aneurysmal 
varix  might  have  been  developed  here  ;  or  an  arterio-venous  aneurysm, 
the  sac  of  which  occupied  the  distended  sheath  of  the  vagus,  might 
have  formed  between  the  vessels  ;  or  again,  a  sac  might  have 
developed  between  the  woimd  of  the  artery  and  the  larynx.  In  fact, 
instances  of  both  the  latter  possibilities  are  included  in  the  section 
devoted  to  injuries  of  the  carotid  arteries.  A  case  has  also  been 
recorded  by  Matas*  in  which  the  communication  between  the 
subclavian  artery  and  vein  was  established  through  the  anterior 
scalene  muscle. 

The  presence  of  an  aneurysmal  varix  may  be  accompanied  by 
no  further  physical  signs  than  the  arterio-venous  murmur  and  bubbling 
thrill.  What  has  been  said  regarding  these  signs  under  the  descrip- 
tion of  arterio-venous  aneurysm  applies  equally  well  to  aneurysmal 
varix.  Besides  these  phenomena,  some  swelling  usually  exists,  due  to 
dilatation  of  the  vein  in  the  vicinity  of  the  communication.  When 
this  dilatation  is  considerable,  communicated  pulsation  from  the 
artery  may  raise  the  question  of  the  existence  of  an  aneurysmal 
sac.  The  dilatation  of  the  vein  may  persist  in  cases  in  which 
the  arterio-venous  aperture  closes  spontaneously.  This  was  so  in 
Sir  W.  Osier's  case  illustrated  in  Fig.  29,  and  the  remaining  vari- 
cose dilatation  might  be  regarded  as  an  illustration  of  a  venous 
aneurysmal  sac. 

In  the  early  stages  some  general  swelling  of  the  limb  may  be 
met  with,  due  to  the  disturbance  of  the  normal  venous  circulation. 
In  the  upper  extremity  this  swelling  is  often  temporary,  but  in 
the  lower  limb  it  often  persists,  and  at  a  later  date  the  super- 
ficial veins  may  become  dilated  and  thickened,  and  develop  vari- 
cosities, A  sense  of  weight  in  the  limb,  or  more  rarely  actual 
pain,  may  call  for  operation ;  but  the  condition  is  not  usually 
sufficiently  serious  to  make  such  a  procedure  necessary. 

Clinical  evidence  is  not  wanting  of  early  spontaneous  closure  of 
arterio-venous  communications.  Thus,  in  a  man  with  a  traversing 
bullet  wound  of  the  right  thigh,  ten  days  after  the  injury  a  local 
arterio-venous  murmur  was  jjresent  in  Scarpa's  triangle,  and  a 
loud  similar  murmur  was  audible  over  the  base  of  the  heart. 
A  fortnight  later,  both  the  local  and  the  cardiac  murmurs  had 
completely  disappeared,  and  no  sign  suggestive  of  any  vascular 
injury  remained. 


*  Transactions  of  the  American  Surgical  Association ,  1901,  xix,  237. 


.si>       GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

TREATMENT    OF    TRAUMATIC    ANEURYSMS. 

The  lines  which  govern  the  treatment  of  any  of  the  forms  of 
tra\unatic  aneurysm  are  influenced,  and  should  be  actually  determined, 
by  the  })eriod  which  has  elapsed  since  the  initial  injury  was  received, 
and  the  stage  of  dcA'clopment  which  has  been  reached. 

Arterial  Haematoma. — If  immediate  treatment  has  not  been 
undertaken,  either  as  a  residt  of  unsatisfactory  conditions  for  opera- 
tion, or  because  the  ha?matoma  has  developed  gradually,  certain 
definite  considerations  should  govern  the  attitude  of  the  surgeon. 

Speaking  generally,  if  the  haematoma  is  of  some  three  days'  or 
more  duration,  an  expectant  attitude  is  advisable,  except  in  the 
presence  of  the  following  conditions  : 

(1)  Increasing  extension  of  the  htcmatoma ;  (2)  Continuing 
haemorrhage,  or  even  continuous  leakage  of  blood  from  the  external 
wound  ;  (3)  Obliteration  of  the  distal  pulse  as  a  result  of  increasing- 
pressure  exerted  by  the  collection  of  fluid  blood  or  firm  clot  ;  (4) 
Symptoms  due  to  pressure  on  neighbouring  organs  or  structures  ; 
(5)  Signs  of  extending  infection  of  the  structures  bounding  the  collec- 
tion of  blood,  in  which  case  prompt  ligature  and  division  of  the 
wounded  artery  to  allow  of  its  retraction  are  highly  necessary. 

Should  none  of  these  conditions  exist,  an  exi^ectant  attitude  is 
advisable  for  several  reasons. 

1.  The  most  serious  contra-indication  to  intervention  at  this 
stage  is  found  in  the  recent  occurrence  of  free  haemorrhage.  This 
prelude  may  involve  loss  of  life  to  the  patient  as  well  as  increased 
risk  to  the  local  vitality  of  the  parts  supplied  by  the  injured 
vessel.  The  manner  in  which  death  is  apt  to  folloAV  operations 
undertaken  after  a  severe  primary  haemorrhage  is  very  character- 
istic. The  operation  may  appear  to  have  been  borne  well,  and 
when  the  patient  is  removed  from  the  table  the  sm-geon  may  see 
no  reason  to  feel  undue  anxiety  as  to  the  further  course  of  the 
case.  Yet,  when  the  man  is  placed  in  bed,  he  fails  to  recover  from 
the  anaesthetic,  and  quietly  sleeps  himself  away  to  death  within  a 
few  hours.  The  danger  to  the  local  vitality  of  the  parts  supplied  by 
the  occluded  vessel  is  also  great.  I  believe  it  is  the  jDrevious  occur- 
rence of  excessive  haemorrhage  which  is  in  great  part  responsible  for 
the  frequency  of  cerebral  symptoms  after  ]5rimary  ligatin-e  of  the 
common  carotid  artery,  as  also  for  many  cases  of  gangrene  of  the  toes, 
foot,  or  leg,  after  ligature  of  the  femoral,  or  the  more  striking  loss  of 
fingers,  hand,  or  even  forearm,  after  primary  ligature  of  the  brachial 
artery,  which  have  all  been  obser^•ed  to  occur.  The  total  volume  of 
blood  in  the  body  has,  in  fact,  been  reduced  to  a  degree  which  renders 
it  impossible  for  a  sufficient  collateral  circulation  to  be  established  to 


HEMATOMA  AND  TRAUMATIC  FALSE  ANEURYSM     83 

maintain  the  vitality  of  the  parts  beyond  the  point  of  oecliision  of 
the  main  vessel. 

The  lessons  to  be  learned  from  these  facts  are,  to  avoid  operation 
if  praetieable,  on  patients  who  have  sviffercd  a  recent  hamorrhage  ;  to 
employ  local  anaesthesia  if  possible  ;  and  to  make  the  most  strenuous 
effort  to  restrict  any  haemorrhage  incident  to  the  operation  to  a 
minimal  amount. 

2.  The  operation  may  be  one  of  considerable  magnitude,  involving- 
extensive  exposure  of  the  tissues  at  an  unfavourable  moment. 
If  a  short  period  be  allowed  to  elapse,  the  following  advantages  may 
be  gained  :  the  general  condition  improves,  cardiac  excitement 
dependent  on  the  injury  subsides,  loss  of  blood  is  to  some  extent  made 
up  for,  compensatory  changes  go  on  in  the  collateral  circulation ; 
and  further,  better  local  conditions  for  the  operation  are  obtained. 
The  cavity  and  the  contained  clot  contract,  and  thus  the  extent  of 
the  field  of  operation  is  reduced;  oedema  svibsides,  not  only  in  the 
part  of  the  body  implicated  but  also  in  the  vascular  cleft  and  the 
walls  of  the  vessels  themselves,  and  the  tissues  generally  become  more 
pliable  and  suited  to  the  necessary  manipulation.  Thus,  the  blood- 
clot  has  become  more  or  less  consolidated  into  a  well-limited  mass,  and 
hence  is  more  readily  removed  ;  the  vessels  themselves  have  become 
more  mobile,  so  that  if  suture  is  undertaken,  not  only  is  less  tension 
needed  to  bring  the  gap  together,  but  the  tendency  for  the  stitches 
to  cut  out  is  also  reduced.  Loss  of  time  is  of  course  entailed,  but  this 
is  not  as  a  rule  accompanied  by  any  lowering  of  the  general  nutrition 
of  the  parts  concerned.  It  is  indeed  remarkable  how  very  little  a 
limb  may  suffer  in  the  continvied  presence  of  the  ha^matoma  ;  while 
occlusion  of  the  main  vessel  at  this  stage  is  often  followed  by  a  shrink- 
ing of  the  limb  which  may  reach  a  very  serious  degree. 

Remote  Operations. — When  neither  primary  nor  early  measures 
for  dealing  with  the  vascular  injury  have  been  taken,  there  is  little 
doubt  that  the  local  conditions  as  a  rule  steadily  improve  for  ultimate 
surgical  intervention  provided  the  patient  be  kept  at  rest.  The 
tissues  surrounding  the  aneurysm  regain  a  more  normal  condition, 
the  only  remaining  troublesome  sequela  of  the  injury  being  found  in 
a  variable  amount  of  cicatricial  tissue  in  the  line  of  the  original  track 
of  the  missile,  and  spreading  along  the  vascular  cleft  to  an  extent 
corresponding  with  that  of  the  blood  which  infiltrated  the  perivascular 
connective  tissue  in  the  primary  stage. 

The  cicatrix  of  the  wound  track  ties  down  and  immobilizes  the 
vessel  at  the  point  of  original  injury,  and  renders  it  necessary  to  free 
this  by  dissection  with  the  knife,  while  the  extension  along  the  vascular 
cleft  necessitates  a  like  procedure  in  order  to  mobilize  the  artery 
sufficiently  if  suture   is  contemplated  ;    or  to  separate   and  free   the 


8!.        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

accompanying  vein,  or  nerves  which  may  have  acquired  an  intimate 
adherence,  if  either  a  j^rovisional  or  permanent  Hgature  needs  to  be 
applied. 

Unless  evidence  is  present  that  steady  progress  towards  sponta- 
neous cure  is  taking  place,  all  arterial  or  arterio-venous  aneurysms 
should  be  subjected  to  operation,  and  the  procediires  which  are 
applicable  may  be  shortly  summarized  as  follows. 

Arterial   False  Aneurysm. — 

1.  Ligatin-e  of  the  artery  above  and  below  the  sac,  and  in  as 
close  proximity  to  the  latter  as  practicable.  It  is  not  advisable 
to  limit  the  occlusion  of  the  trunk  to  the  proximal  side  alone,  for 
although  this  procedure  generally  suffices  to  prociu'e  solidification 
of  the  sac,  a  risk  of  the  detachment  of  emboli  from  the  interior 
of  the  sac  exists,  and  I  have  seen  this  sequence  with  unfortunate 
results.  Application  of  a  distal  ligature  necessitates  only  a  little 
more  free  dissection,  and  should  be  laid  down  as  the  rule,  unless 
exceptional  difficulties  should  render  its  adoption  inadvisable. 

2.  The  sac  may  be  excised  after  the  application  of  a  proximal 
and  distal  ligature.  In  dealing  with  the  false  aneurysmal  sacs  follow- 
ing gunshot  injury,  precaution  is  highly  necessary  in  order  to  ensure 
that  a  neighbouring  nerve  is  not  a  constituent  of  the  actual  wall.  It 
is  not  at  all  an  uncommon  thing  to  find  a  more  or  less  injured  nerve 
trunk  spread  out  widely  on  the  surface,  or  even  buried  in  the  Avail,  of 
the  aneurysm. 

3.  The  cavity  of  the  sac  may  be  obliterated  by  plication  of  its 
walls.  This  method,  although  simple  and  easy  of  application,  has 
some  disadvantages.  It  increases  the  risk  of  immediate  thrombus 
formation  in  the  artery,  and  it  may  be  followed  by  recurrence  as  a 
result  of  opening  out  of  the  folds. 

4.  The  sac  may  be  dissected  away  from  the  artery,  and  the 
opening  in  the  vessel  wall  closed  by  suture.  This  is  the  ideal  method 
if  the  defect  in  the  wall  of  the  vessel  is  moderate  in  extent.  When 
the  defect  is  large,  if  the  aneurysm  be  one  of  some  standing  so  that 
rio  doubt  can  exist  as  to  the  strength  of  the  adhesion  between  the 
opening  in  the  artery  and  the  margins  of  the  sac,  the  method  may  be 
modified  by  removing  the  main  part  of  the  sac  but  preserving  enough 
of  its  base  to  unite  and  close  over  the  opening  in  the  vessel.  This 
modification  has  obvious  technical  advantages,  both  in  facilitating 
introduction  of  the  stitches  and  in  avoiding  narrowing  of  the  lumen 
of  the  vessel.  As  far  as  my  experience  goes  it  is,  however,  much  less 
satisfactory  than  imion  of  the  actual  margins  of  the  artery,  and  is 
more  liable  to  be  followed  by  idtimate  thrombosis.  This  probably 
depends  upon  the  absence  of  a  proper  endothelial  lining,  which  renders 
the  line  of  imion  a  more  likely  starting-point  for  clotting.     In  one  case 


H/FMATOMA  AND   TRAUMATIC  FALSE  ANEURYSM     85 

in  which  I  adopted  it,  the  axillary  artery  thrombosed  and  complete 
locar  obstruction  took  place  before  the  main  wound  was  closed. 
Arterio-venous   Aneurysm. — 

1.  Ligature  of  both  artery  and  vein  on  the  proximal  and  distal 
sides  of  the  sac.  This  method  may  be  employed  when  difficulty  is 
likely  to  attend  removal  of  the  sac.  If  it  be  chosen,  great  care  must 
be  exercised  to  ensure  that  the  excluded  sac  be  not  further  supplied 
by  a  branch  of  the  artery.  The  existence  of  such  branches  is  common, 
and,  as  we  know,  may  have  determined  the  actual  location  of  the 
injury  or  prevented  the  escape  of  the  vessel  from  injury  by  checking 
possibility  of  displacement. 

Many  failures  after  this  operation  are  to  be  attributed  to  the  fact 
that  such  branches  have  escaped  detection  at  the  time  of  operation, 
and  although  the  reduction  of  the  supply  has  been  at  first  sufficient 
to  abolish  any  pulsation  or  murmur,  both  may  reappear  and  gradually 
increase  at  a  later  period. 

2.  The  addition  of  excision  of  the  sac  to  the  above  procedure 
adds  little  to  its  difficulty  or  gravity,  and  is  preferable  as  eliminating 
all  chance  of  recurrence. 

3.  Mobilization  of  the  vessels,  removal  of  the  sac,  and  repair  of 
the  defect  in  the  walls  of  the  artery  and  vein  by  suture.  This  opera- 
tion is  preceded  by  the  application  of  four  provisional  ligatures  to 
control  the  circulation  during  the  process  of  suture  and  removal  of 
the  sac.  If  a  direct  opening  exists  between  the  artery  and  vein,  the 
latter  should  be  opened  up  freely  ;  the  communication  is  thus  exposed, 
and  may  often  be  stitched  up  without  any  fiu'ther  preparation.  If 
the  sac  be  situated  between  the  vessels,  it  should  be  opened  first,  and 
the  communication  can  be  stitched  from  this  aspect.  If  the  aneurysm 
be  on  the  free  aspect  of  the  artery,  the  sac  is  removed  and  the 
opening  in  the  vessels  sewn  up. 

A  word  of  caution  should  be  added  as  to  the  free  utilization  of 
flaps  obtained  from  the  wall  of  an  established  aneurysmal  sac,  to  make 
up  for  extensive  loss  of  substance  of  the  arterial  wall.  Arteries  re- 
constructed in  this  manner  are  liable  to  subsequent  dilatation,  and  it 
must  be  remembered  that  the  conversion  of  an  arterio-venous  into 
an  arterial  aneurysm  is  not  prognostically  desirable. 

Aneurysmal  Varix.  —  The  indications  for  operation  for  this 
condition  are  less  precise  than  in  the  case  of  the  aneurysms.  There 
is  no  doubt  that  many  aneurysmal  varices,  especially  in  the  upper 
extremity,  do  not  call  for  operation,  and  may  be  left  untouched 
without  risk  to  the  patient.  Either  pain,  increasing  local  distention 
of  the  vein,  or  signs  of  increasing  and  troublesome  obstruction  to  the 
peripheral  venous  circulation,  may  render  operation  advisable  or 
necessary. 


86        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

The  vessels  may  then  be  ligatured  above  and  below  the  level  of 
the  comniTinieation,  and  the  varix  exeised.  A  far  preferable  method 
is  to  elosc  the  eomnmnicating  o]iening  by  suture,  as  has  been  already 
described  imder  the  heading  of  arterio-venous  aneurysm.  In  pure 
aneurysmal  varices  the  almost  invariable  route  to  the  anastomotic 
opening  should  be  through  the  vein  ;  if  this  procedure  be  adopted, 
the  closure  of  the  opening  into  the  artery  is  easy,  and  that  of  the 
incision  made  into  the  vein  simple  in  the  extreme. 

When  a  short  channel  connects  the  two  vessels,  this  may  be 
occluded  by  the  simple  method  of  applying  a  ligature  around  it. 
Several  cases  have  been  reported  in  which  this  plan  has  been  success- 
fully adopted. 


87 


CHAPTER     V. 

THE     IMMEDIATE     AND     REMOTE     EFFECTS 

OF     OCCLUSION     OF     THE   MAIN     BLOOD-VESSELS     ON     THE 

VITALITY     OF     PARTS     SUPPLIED. 

Complete  occlusion  of  the  arteries  may  be  a  result  of  thrombosis 
following  contusion,  with  a  varying  degree  of  disintegration  of  the 
walls  of  the  vessels  ;  of  thrombosis  secondary  to  a  wound  ;  or  of 
obliteration  of  the  lumen  by  a  ligature  applied  by  the  surgeon.  What- 
ever be  the  actual  cause  of  interruption  of  the  main  current,  some 
disturbance  of  the  normal  process  of  nutrition  of  the  parts  situated 
in  the  area  of  peripheral  distribution  of  the  occluded  vessel  is 
inevitable,  and  to  some  extent  must  be  permanent  in  its  effects. 
Great  variation  in  degree  is  met  with  in  this  respect.  It  will  be 
convenient  first  to  consider  the  immediate  and  minor  effects,  and 
then  trace  the  gradation  of  events  from  temporary  and  practically 
negligible  phenomena  upwards,  to  the  occurrence  of  actual  necrosis 
of  the  tissues  implicated. 

The  first  obvious  effects  of  obstruction  to  the  normal  blood-flow 
are  seen  in  local  pallor,  or,  if  both  artery  and  vein  be  implicated, 
cyanosis  ;  a  fall  in  the  local  temperature  ;  and  lessened  functional 
capacity — the  latter  manifested  in  lowering  of  the  common  sensation, 
the  incidence  of  subjective  sensations,  and  loss  of  muscular  power 
progressing  to  paresis  or  actual  paralysis.  These  signs  may  be 
fugitive,  or  at  most  persisting  for  hours  or  days  ;  in  other  instances 
they  may  be  present  for  weeks  or  months,  or  they  may  become 
permanent. 

Associated  Ifesions  of  the  peripheral  nerves  are  common  in  con- 
nection with  vascular  injuries,  in  which  circumstances  all  the 
symptoms  are  more  pronounced  in  character.  The  frequency  with 
which  this  association  is  met  has  in  fact  led  the  pure  effects  of 
anaemia  to  be  less  fully  appreciated  than  they  deserved  prior  to  the 
work  of  H.  Meige  and  Athanassio-Benisty.  Cases  in  which  the  effects 
of  occlusion  of  the  main  vessel  of  a  limb  had  been  compared  with  the 
condition  termed  muscular  ischa?mia  or  von  Volkmann's  contracture, 
and  also  those  in  which  gangrene  of  a  limb  followed  a  slight  injury 
after  occlusion  of  the  main  arterial  trunk,  had  been  reported  ;  and 
the  question  of  the  effect  of  "a  nervous  element  of  unknow^i  quantity, 


88       GUNSHOT    IN  J  U  HIES    TO    THE    BLOOD-VESSELS 

the  effect  of  the  form  of  injury  on  the  vasomotor  nerves  accompanying 
the  great  vessels,  had  been  taken  into  consideration."  *  Until  this 
war,  however!,  little  opportiniity  had  existed  for  the  observation  of  a 
large  number  of  cases. 

In  ])ublished  reports  of  operations  for  either  recent  wounds  or  for 
traimiatic  aneurysms  by  ligature  of  the  vessels,  it  is  common  to  meet 
with  the  broad  statement,  "  The  condition  of  the  limb  was  excellent." 
These  reports  are  indeed  well  enough  founded  ;  the  functional 
capacit}^  of  the  limb  suffices  for  all  ordinary  efforts,  the  skin  and  nails 
are  normal  in  appearance,  a  peripheral  pulse  may  have  re-developed, 
and  when  the  patient's  limb  is  exposed  for  inspection  it  may  appear 
normal  in  all  respects.  Even  in  these  instances,  however,  measure- 
ment of  the  limb  will  show  it  to  have  lost  in  volume,  if  an  artery  in 
the  upper  segment  has  been  occluded.  Comparison  with  the  un- 
injured limb  will  show  it  to  have  suffered  a  permanent  decrease  in 
circumference  of  from  half  an  inch  to  an  inch,  this  decrease  being 
most  marked  in  the  forearm  and  leg  resiDcctively. 

It  is  rare  to  meet  with  a  re-developed  distal  pulse  which  approaches 
the  normal  in  strength  and  volume.  Palpation  usually  reveals  one  of 
greatly  diminished  volume.  It  would  be  unreasonable  to  exjDcct  that 
the  main  vessel  can  ever  regain  its  normal  calibre  when  the  circulation  is 
mainly  collateral  in  character  ;  but  in  examining  a  considerable  number 
of  cases  at  an  interval  of  two  or  three  weeks  after  a  vessel  has  been 
ligatured,  I  have  been  struck  with  the  late  period  at  which  an  appre- 
ciable pulse  appears.  In  the  case  of  the  brachial  artery,  three  or  foiu* 
days  usually  suffice  for  the  reappearance  of  a  palpable  radial  pulse, 
but  this  is  then  usually  weak  and  very  inconstant  in  strength.  In 
the  lower  extremity  the  reappearance  of  the  posterior  tibial  pulse 
after  ligature  of  the  femoral  artery  is  a  much  later  occurrence,  tAVo 
weeks  being  a  rare  and  early  date  ;  it  is  often  impalpable  for  weeks 
or  months. 

Estimation  of  the  peripheral  blood-pressiu'c  will  also  show  this 
to  be  lower  than  that  of  the  sound  limb  in  the  majorit}^  of  cases,  a 
decrease  of  10  to  20  mm.  of  mercury  being  common. 

Loss  of  volume  in  a  limb  may  certainly  be  ascribed  to  the  luicom- 
plicated  effect  of  a  decreased  blood-supply  which  is  permanent.  It 
is  the  development  of  these  persistent  changes  that  has  afforded  the 
strongest  argument  for  attempting  to  repair  the  blood-vessels  by 
plastic  measures,  rather  than  to  effect  permanent  occlusion. 

In   cases   which   progress   favourably   after   ligation   of  a   trunk 


*  G.  H.  Makins,  Bradshmv    Lecture,    1914,  p.  49  ;     Surgical   Experiences   in 
Sonth   Africa,  1st  ed.,  1901,  p.  152. 


EFFECTS    OF    OCCLUSION    OF    BLOOD-VESSELS        89 

vessel,  the  immediate  changes  noted  above  are  followed  by  some 
phenomena  of  a  more  lasting  character.  These  consist  in  an  increase 
in  firmness  of  consistence  of  the  muscles  of  the  area  implicated, 
with  a  varying  degree  of  limitation  of  freedom  and  activity  of 
movement.  This  change  depends  in  part  on  the  exudation  of 
fluid  within  the  muscle  sheath,  and  in  part  in  a  change  in  the 
muscle  itself  which  has  been  described  as  resembling  an  early  stage 
of  rigor  mortis. 

Clinically  this  condition  is  of  interest,  in  that  it  tends  to  convey 
a  false  impression  of  the  actual  condition  when  the  limb  is  inspected. 
The  slight  swelling,  together  with  accurate  retention  of  the  normal 
outline  of  the  limb,  suggest  in  fact  the  absence  of  any  morbid  change, 
imtil  comparison  with  the  uninjured  limb  reveals  in  the  latter  the 
flabby  condition  which  commonly  follows  disuse  for  a  short  period. 

Together  with  these  changes  in  the  muscles,  a  certain  degree  of 
loss  of  freedom  of  movement  of  the  joints  also  develops,  in  part  due 
to  peri-articular  oedema  and  infiltration  ;  in  part  to  the  joint  having 
been  kept  at  complete  rest.  Massage,  electrical  treatment,  and  careful 
exercises,  however,  will  overcome  any  disability  in  such  instances, 
and  the  typical  '  good  result  '  will  be  attained. 

In  less  favourable  eases,  rapid  wasting  of  the  limb  follows 
occlusion  of  its  main  artery.  This  event  is  most  striking  in  the  case 
of  the  common  femoral  and  axillary  trunks,  and  is  seen  in  its  extreme 
degree  in  patients  who  may  require  to  be  ojaerated  upon  while  suffer- 
ing from  general  systemic  infection.  In  my  own  experience  this 
rapid  wasting  is  seen  only  after  operations  performed  at  an  early 
date,  when  the  patients  are  suffering  from  great  decrease  in  general 
volume  of  blood,  or  from  woiuid  infection  ;  I  have  never  seen  it  occur 
as  a  consequence  of  a  remote  operation,  and  it  is  certainly  never 
induced  by  the  presence  of  an  aneurysm.  In  estimating  the  amount 
of  wasting  in  such  cases,  it  must  be  remembered  that  the  mere 
absolute  disuse  of  the  limb  plays  a  not  unimportant  part,  and  in  the 
case  of  the  lower  extremities  the  iminjured  limb  will  also  be  found  to 
have  lost  considerably  in  volume  as  a  result  of  confinement  in  the 
recumbent  position.  In  many  cases  the  early  stages  of  change  in  the 
musculature  of  the  limb  may  be  masked  by  general  oedema  similar 
to  that  which  follows  the  too  tight  application  of  a  bandage  to  a 
fracture.  In  a  certain  proportion  of  the  cases,  early  wasting  of  the 
muscles  may  be  followed  by  the  development  of  the  rigid  inelastic 
condition  characteristic  of  Volkmann's  contracture,  with  deformity 
of  the  joints  and  more  or  less  complete  loss  of  function  of  the  limb. 

In  the  most  unfavourable  class  of  case,  short  of  early  massive 
gangrene  of  the  limb,  the  sudden  local  ansemia  consequent  on  ligature 
of  the  vessel  is  followed  by  more  rapid  destructive  changes  in  the 


90       GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

muscles.  \\\  excellent  (lescrii)tic)n  of  these  is  given  by  Captains  Harold 
Burrows  and  A.  ^V.  Stott.* 

"  The  limb  was  amputated  on  the  fourteenth  day  after  ligature 
of  the  popliteal  artery.  No  concm'rent  nerve  lesion  was  present.  The 
limb  was  swollen  and  hard,  the  tips  of  the  toes  and  a  j^ateh  of  skin 
upon  the  dorsiun  of  the  foot  wei*e  gangrenous,  otherwise  the  foot  was 
warm.  There  was  no  loss  of  sensation  except  in  the  limited  gangrenoiis 
area,  but  there  was  absolute  paralysis  of  all  the  muscles  below  the 
knee,  except  for  very  slight  movement  which  could  be  made  by  the 
gastrocnemius  and  soleus. 

"After  amputation,  examination  showed  a  striking  alteration  in 
the  colour  of  all  the  mxiscles  ;  this  was  pale,  and  scarcely  a  tinge  of 
red  existed  except  in  the  distal  portions.  The  gastrocnemius  was 
affected  in  its  lower  two-thirds,  the  soleus  in  its  lower  third  only. 
The  upper  portions  of  these  muscles  were  of  normal  colour  and  looked 
healthy.  Transition  from  the  healthy  tissue  above  to  the  altered 
tissue  below  was  gradual,  and  in  an  intermediate  zone  a  streaky  appear- 
ance was  displayed,  bundles  of  red  fibres  being  interspersed  amongst 
the  pale  ones."  Captain  Stott  made  histological  specimens  from  the 
muscles,  and  reiaorted  as  follows  :  "  Portions  of  the  peronei  and  the 
gastrocnemius  muscles  were  cut ;  each  showed  gross  pathological 
changes.  No  normal  muscle  fibres  were  seen.  In  sections  stained 
with  ha^malum  and  eosin,  the  general  impression  given  was  that  of 
an  anaemic  infarct.  The  muscle  fibres  and  interstitial  tissue  stained 
an  uniform  pink.  The  fibres  showed  various  stages  of  degeneration  ; 
some  presented  almost  normal  striation  but  no  nuclei,  others  had 
completely  lost  all  striation  and  appeared  as  granular  masses.  Fibres 
exhibiting  different  degrees  of  change  were  often  found  next  each 
other.  The  majority  of  the  fibres  appeared  swollen,  some  were  broken 
up  into  irregular  masses,  others  were  split  into  longitudinal  fibrilhe  or 
transverse  discs.  There  was  no  hyaline  degeneration,  and  no  gross 
fatty  change  was  seen.  The  interstitial  tissue  appeared  oedematous, 
stained  a  faint  pink  with  van  Gieson,  and  was  almost  cell-less.  There 
were  few  capillaries.  Throughout  the  sections  there  Avas  little  trace 
of  inflammatory  reaction.  The  large  vessels,  arteries  and  veins,  con- 
tained blood  and  no  blood-clot,  and  apjDeared  normal." 

In  rare  instances  this  process  of  muscular  degeneration  and  dis- 
integration may  be  equally  complete  but  much  slower  in  progress. 
Thus,  in  a  patient  whose  superficial  femoral  artery  had  been  ligatured, 
extreme  wasting  of  the  thigh  and  leg  ensued.  After  a  lapse  of  some 
three  weeks,  the  area  corresponding  with  the  compartment  of  the 
leg  containing  the  anterior  tibial  group  of  muscles  became  soft  and 

*  British  Medical  Journal,  1918,  vol.  i,  Feb.,  p.   199. 


EFFECTS    OF    OCCLUSION    OF    BLOOD-VESSELS        01 

fluctuating.  An  incision  gave  vent  to  a  flow  ol"  grunions  IJuid  corres- 
ponding in  volume  to  the  whole  mass  of  the  muscles,  which  latter  had 
suffered  a  species  of  moleciflar  disintegration  quite  irrespective  of 
infection  from  without.  The  overlying  skin,  though  dry  and  scaly, 
retained  its  vitality,  and  the  wasted  musculatures  of  the  peroneal 
region  and  calf  also  retained  their  structural  continuity. 

The  development  of  a  condition  identical  with  that  described  by 
von  Volkmann  as  muscular  ischfcmia  is  easily  comprehensible  in  view 
of  its  familiarity  as  a  consequence  of  obstniction  to  the  circulation  by 
tight  bandaging  or  the  too  tight  or  jirolonged  apj^lication  of  a  tourni- 
quet. Although  even  in  this  condition  the  association  of  nervous 
influence  in  the  ultimate  results  has  been  debated,  I  think  it  must  be 
conceded  that  local  anaemia  is  competent  to  explain  the  occurrence  of 
the  changes  met  with,  and  that  it  plays  the  all-important  part  in  them 
all.  It  is  significant  that  the  muscles,  the  most  highly  organized 
element  of  the  limbs,  suffer  first  and  the  most  severely  of  all  the  tissues. 
Reference  has  been  already  made  to  the  immediate  signs  of  nerve 
disturbance  which  may  follow  an  arterial  injury,  and  also  to  the  attempt 
made  by  Captain  Burrows  to  establish  a  definite  line  of  separation  in 
the  signs  of  those  cases  in  which  the  arterial  injury  is  complete  or 
partial.  He  suggests  that  in  those  in  which  the  obstruction  is  com- 
plete, the  signs  of  nervous  disturbance  are  a  direct  result  of  ischa^mia, 
while  those  accompanying  lesions  only  partially  obstructing  the  cir- 
culation are  of  '  reflex  '  nervous  nature.  Such  a  distinction,  if  reliable, 
would  be  of  some  clinical  and  prognostic  value  ;  but  it  is  not  easy  of 
acceptance,  even  putting  upon  one  side  the  difficulty  in  absolutely 
excluding  concomitant  nerve  injury  of  minor  degree.  It  appears 
equally  reasonable  to  ascribe  the  differences  in  the  signs  to  varying 
degrees  of  local  anaemia,  as  also  the  fact  that  the  '  reflex  '  symptoms 
clear  up  with  the  greater  rapidity. 

H.  Meige  and  Athanassio-Benisty,*  in  the  course  of  investigation 
of  a  number  of  cases  in  which  vasomotor,  trophic,  and  secretory 
disturbances  were  present  and  considered  to  be  consecutive  to  division 
of  or  serious  damage  to  the  peripheral  nerves  of  the  limb,  observed 
that  these  changes  only  appeared  in  instances  in  which  an  associated 
arterial  lesion  was  present.  They  therefore  laid  down  the  rule  that  a 
co-existing  arterial  lesion  is  suggested  in  any  case  in  which  the  skin 
of  the  hands  or  feet  has  assumed  a  purplish-red  tint  or  a  blue  cyanotic 
hue,  a  tense  glossy  appearance  with  tumid  succulent  character,  to- 
gether with  signs  of  trophic  degeneration  of  the  nails  or  terminal 
ulceration  of  the  digits.  Athanassio-Benisty  draws  a  comparison 
between  the  condition   of  a  hand  the  subject  of  an  uncomplicated 

*  Formes  Cliniques  des  Lesions  des  Nerfs,  1918,  p.   214. 


92       GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

lesion  of  the  median  nerve,  and  one  in  wliicli  tlie  main  vaseular  supply 
has  been  interrupted,  as  follows  : — 

The  '  median  hand  '  is  trembling,  and  more  or  less  emaciated, 
hot,  red,  and  painful ;  it  reacts  promptly  to  external  influences,  and 
is  in  a  state  of  what  may  be  called  perpetual  combustion. 

The  '  vascular  hand  '  is  cold,  purplish  or  dusky  in  hue,  with  a 
shiny  scaling  skin  ;  it  is  insensitive  objectively  and  subjectively.  If 
the  vascular  lesion  be  of  minor  gravity,  there  may  be  neuralgia  of  the 
articulations,  or  of  the  margins  of  a  digit  or  the  member,  or — as  in 
arteritis  obliterans — the  neuralgia  may  follow  the  course  of  a  nerve. 
Causalgia,  if  present,  is  less  intense  and  persistent  than  in  the  case  of 
the  median  hand. 

These  authors  have  approached  the  subject  from  a  neurological 
standpoint,  and  in  the  majority  of  the  cases  investigated  it  is  clear 
that  associated  arterial  and  nervous  lesions  were  present,  since  it  is 
pointed  out  that  exploratory  operations  for  the  mobilization  of  nerve 
trunks  were  always  followed  by  improvement  in  the  trophic  con- 
ditions. The  investigations  none  the  less  shed  an  important  light  on 
the  effects  produced  by  interference  with  the  local  blood-supjDly. 

The  question  of  the  relation  of  the  vascidar  and  nervous  elements 
respectively,  in  the  production  of  trophic  changes,  has  been  investi- 
gated from  another  aspect  by  Leriche  and  Heitz.*  They  point  out 
that  the  researches  of  Babinsky,  Froment,  and  Heitz  on  the  circulatory 
disturbances  which  accompany  paralyses  and  reflex  contractures, 
have  shown  a  vasomotor  contraction  to  be  a  constant  element,  and 
that  this  contraction  of  the  vessels  can  be  temporarily  overcome  by 
the  application  of  heat,  with  consequent  disparition  of  most  of  the 
objective  signs  of  a  muscular  nature  which  accompany  motor  dis- 
orders. Leriche  and  Heitz  regard  an  obliterated  main  vessel  as  a 
'  nerve,'  the  fibrovis  cord  representing  a  segment  of  the  vasomotor 
chain,  since  it  contains  the  remains  of  the  perivascular  sympathetic. 
Further,  that  the  '  nerve  '  is  an  abnormal  one,  of  Avhich  the  functions 
are  distorted. 

On  this  theory  Leriche  has  based  his  operation  of  perivaseidar 
symjjathectomy,  i.e.,  either  the  dissection  away  of  the  perivascular 
sheath  to  the  extent  of  an  inch  or  more,  or  the  resection  of  a  corre- 
sponding length  of  the  injured  vessel  together  with  its  sheath.  The 
stripping  away  of  the  cellular  sheath  immediately  enveloping  the  vessel 
is  followed  at  once  by  an  intense  contraction  of  the  artery  in  the  whole 
extent  involved  by  the  operation,  while  a  secondary  vasomotor  dilata- 
tion succeeds  the  initial  contraction.  This  secondary  reaction  persists 
for  two  or  three  weeks,  the  first  resvilts  being  a  considerable  increase 

*  Lyon  Chirurgicale,  xiv,  No.  4,  p.  754. 


EFFECTS    OF    OCCLUSION    OF    BLOOD-VESSELS        m 

in  the  local  temperature  of  the  part  ol'  the  body  involved,  increase  in 
metabolic  and  katabolic  changes,  and  a  manifest  effect  upon  the  power 
of  contraction  of  the  voluntary  muscles.  Leriche  considers  this 
operation  justifiable  on  the  groiuids  that  the  vasomotor  dilatation 
obtained  is  more  constant  and  persistent  than  that  induced  by  the 
employment  of  heat,  baths,  etc.,  and  on  the  amelioration  of  the 
symptoms  which  he  has  observed  to  follow  the  procedure  in  six 
recorded  instances. 

Some  significant  observations  on  the  relative  parts  played  by  the 
vascular  and  nervous  elements  respectively,  in  the  causation  of  trophic 
lesions,  have  been  made  by  J.  B.  Stopford.*  These  tend  to  elucidate 
the  serious  effect  of  association  of  the  two  elements  in  influencing  or 
even  aggravating  the  disturbance  of  the  normal  process  of  nutrition, 
and  causing  its  persistence.  It  is  pointed  out  as  a  common  experience 
that  vasomotor  and  trophic  changes  are  an  outstanding  feature  of 
many  eases  of  incomplete  division  of  nerves  which,  when  consequent 
on  gunshot  injury,  are  almost  invariably  accompanied  by  evidence  of 
nerve  irritation  Stopford  considers  that  confusion  has  been  caused 
by  attributing  the  origin  of  these  disturbances  to  concomitant  vascular 
lesions,  and  that  the  view  that  uncomplicated  nerve  injury  is  respon- 
sible for  profound  vasomotor  symptoms  is  very  strongly  supported  by 
experience  of  the  modification  which  is  immediately  effected  in  the 
vasomotor  manifestations  by  neurolysis  or  resection  and  secondary 
suture  of  nerves,  in  the  absence  of  any  possible  disturbance  of  the 
arterial  trunks.  Thus,  as  to  the  remote  changes  in  a  limb  in  which  a 
vascular  and  nerve  lesion  are  associated,  he  considers  there  is  strong- 
reason  to  believe  that  irritative  nerve  lesions  can  produce  changes  in 
the  walls  of  the  arteries  supplied  by  the  inaplieated  nerve,  and  agrees 
with  T.  W.  Todd  that  the  trophic  lesions  are  preceded  by  vascular 
changes.  It  is  suggested  that  the  muscular  contractures  which  follow 
uncomplicated  lesions  of  the  peripheral  nerves  are  due  to  an  ischfemia 
secondary  to  vascular  changes  caused  by  the  injury  to  the  nerve.  In 
support  of  this  opinion  a  report  is  furnished  of  the  histological  changes 
found  in  the  arteries  of  a  limb  in  which  the  popliteal  nerves  had 
suffered  injury  but  the  popliteal  vessels  had  escaped  all  implication. 
An  endarteritis  localized  to  peripheral  branches  of  the  vessel  was 
demonstrated,  and  illustrations  are  given  of  the  changes  in  the  wall  of 
the  dorsalis  pedis  artery. 

The  views  expressed  by  Stopford  are  not  in  agreement  with  those 
of  Meige  and  Athanassio-Benisty  ;  yet  the  practical  conclusion  drawn 
from  them,  that  early  relief  from  irritation  should  be  striven  for  in 
order  to  prevent  the  occurrence  of  secondary  vascular  changes  in  the 

*  Lancet,  1918,  i,  Mar.  30,  p.  665. 


94       GUNSHOT    INJLRIES    TO    THE    BLOOD-VESSELS 

distal  jiart  of  the  circulation,  is  of  great  practical  imjiortance,  and  is 
in  strict  consonance  with  their  observation  that  ini])rovenicnt  invari- 
abty  follows  measures  inidertaken  for  the  mobilization  of  injiued 
nerve  trunks,  and  hence  early  intervention  is  justified. 

The  question  has  been  dealt  with  at  some  length,  because  in 
arteries  such  as  the  axillary,  where  the  nerves  can  scarcely  escai^c 
concurrent  injury,  the  results  of  the  combined  injury  are  especially 
bad  ;  while  the  frequency  with  which  the  arterial  lesion  heals  spon- 
taneously, as  a  result  of  thrombosis,  removes  the  vascular  injuiy  itself 
from  the  category  in  which  operation  is  necessary. 

THE   OCCURRENCE  OF   ANEMIC   GANGRENE. 

The  development  of  gangrene  is  a  common  sequence  of  gunshot 
injuries  to  the  arteries,  whether  the  vessel  be  operated  upon  or  not. 
Old  collected  statistics  show  the  incidence  of  gangrene  following  ligature 
of  the  main  arteries  from  all  causes  to  vary  from  6  to  12  per  cent.  A 
consideration  of  the  cases  upon  which  this  essay  is  founded  appears  to 
show  that  this  estimate  is  too  Ioav  in  the  case  of  gunshot  injuries  ; 
but  it  must  be  remembered  that  a  consulting  surgeon  with  the  army 
has  miost  of  the  unsatisfactory  cases  brought  to  his  notice,  while  those 
which  progress  uneventfully  will  escape  attention  amongst  the  very 
large  number  of  wounded  men  nominally  coming  into  his  purview.  It 
is  obvious,  however,  that  series  of  collected  statistics  from  published 
records  contain  many  sources  of  fallacy  also. 

It  may  be  of  interest  therefore  to  offer  three  small  tabular  state- 
ments to  illustrate  the  variations  w^hich  may  occur  in  the  experience 
of  one  individual,  the  circumstances  to  which  these  variations  are 
attributable,  and  how  they  may  influence  the  apparent  results. 

Table  I  includes  86  operations  performed  at  the  casualty  clearing 
stations  by  different  sm-geons,  but  the  cases  may  be  regarded  as  a 
consecutive  series,  and  the  patients  to  have  been  subject  to  the  same 
conditions.  The  large  majority  of  these  j^atients  Avould  only  have 
remained  under  the  personal  observation  of  the  operator  for  a  period 
of  less  than  ten  days.  The  incidence  of  anamic  gangrene  amounts 
to  10-5  per  cent,  and  that  of  gas  gangrene  to  7-8  per  cent. 

Table  II  includes  42  operations  performed  at  casualty  clearing 
stations  for  the  most  part,  but  in  which  progress  was  sufficiently 
favourable  to  allow  the  patients  to  be  evacuated  to  a  base  hospital  in 
London.  As  the  primary  faihires  have  been  Aveeded  out,  by  ampu- 
tation or  otherwise,  the  apparent  incidence  of  ana-mic  gangrene  falls 
to  7-1  per  cent,  and  gas  gangrene  has  disappeared  from  the  table. 

Table  III  shows  the  variation  in  incidence  of  gangrene  after 
operations  on  the  femoral  and  popliteal  arteries  alone,  at  the  three 
various  positions  in  the  line.     With  regard  to  the  scries  collated  on 


EFFECTS    OF    OCCLUSION    OF    BLOOD-VESSFLS        9.5 
Table  I. 


Artery- 

Cases 

Gangrene 

Gas 
Gangrene 

Injury  to 
Nerves 

Deaths 

Axillary 
Brachial        .  . 
Femoral 
Popliteal 
Posterior  tibial 

27 
11 
27 
13 
8 

2 

4 
2 

1 
5 

.5 
3 
1 
2 

1 

1 

4 

Ampu. 
2 

.5 

4 

Totals 

86 

8 

10'5  per  cent 

6                 11 

7-8  per  cent    14-4  per  cent 

6 

7-8% 

11 

14-4  % 

Table  II. 


Artery 

Cases 

Gangrene 

Gas 
Gangrene 

Injury  to 
Nerves 

Deaths 

Axillary 
Brachial 
Femoral 
Popliteal 
Posterior  tibial 

3 

7 

18 

6 

8 

42 

1 
1 
1 

— 

2 
1 
2 
3 
1 

— 

Totals 

3 

7'1  per  cent 

— 

9 

21-4  per  cent 

— 

Table  III. 


Artery 

Table  I.— C.O.S. 

Table  II.— Base 

Table  III.— L.  of  Com. 

Femoral 
Popliteal 

27 
13 

Gaagreae 
4  =  14-8% 
2  =  15-3% 

18 
6 

Gangrene 
1=   5-5% 
1  =  16-6% 

93 

48 

Gangrene 
19  =  20-4% 
19  =  39-5°o 

the  lines  of  communication,  I  am  inclined  to  believe  it  most  nearly 
represents  the  result  likely  to  be  attained  in  any  war  of  movement, 
when  the  men  are  subjected  to  the  inconvenience  of  early  transport, 
and  are  unable  to  be  dealt  with  effectively  at  special  operating  centres 
quite  near  the  front. 

I'urther  details  regarding  the  incidence  of  gangrene  will  be  found 
in  the  sections  dealing  with  the  special  vessels.  It  may  be  convenient, 
however,  to  summarize  shortly  the  conditions  which  favour  the  occur- 
rence of  gangrene  after  wounds  of  arteries  received  on  militaiy 
service.  These  conditions  amply  account  for  the  unsatisfactory 
nature  of  the  results    obtained,   in  comparison  with  those  following 


96       GUNSIIOr   INJURIES    TO    THE    nLOOD-VESSELS 

remote  operations,  in  which  the  supervention  of  gangrene  is  sullici- 
ently  rare  to,  merit  but  sHght  consideration. 

1.  Decrease  in  the  total  amount  of  circulating  blood,  due  to  loss 
by  ])riniary  hirmorrhage,  and  consequent  fall  in  the  blood-pressure. 

2.  Exposure  to  cold,  and  exhaustion  ;  in  several  cases  gangrene 
after  an  arterial  injiuy  has  been  accompanied  by  a  condition  of 
trench  foot  or  hand  in  the  uninjured  limb. 

3.  The  prolonged  application  of  the  tourniquet,  especially  dan- 
gerous in  the  case  of  the  popliteal  artery. 

4.  Infection  of  the  wound,  independently  of  gas  gangrene. 

5.  General  systemic  infection,  and  secondary  ha?morrhage. 

6.  Associated  injury  to  nerves,  especially  noticeable  in  the  upper 
extremity  in  connection  with  injury  to  the  median  nerve. 

7.  The  extent  and  severity  of  the  injiu-}^  to  the  soft  parts  and 
to  the  bones  which  may  be  associated  with  the  arterial  lesion. 

In  connection  with  the  above  conditions,  it  is  noteworthy  that 
among  175  injuries  to  the  femoral  artery,  in  11,  or  6-29  per  cent, 
gangrene  developed  prior  to  the  performance  of  any  operation.  The 
occurrence  of  gangrene  as  a  result  of  local  spontaneous  thrombosis  is 
also  suggestive,  in  so  far  as  it  illustrates  the  danger  of  sudden  abro- 
gation of  the  main  blood-supply,  and  it  forms  one  of  the  grovmds  upon 
which  an  expectant  attitude  is  based,  in  what  may  be  called  the  inter- 
mediate stage  in  the  course  of  vascular  injuries. 

The  cases  included  in  the  series  afford  little  evidence  of  embolism 
being  a  frequent  factor  in  the  production  of  gangrene  ;  only  four 
instances  occurred  among  the  injuries  to  the  limb  arteries ;  and 
experience  has  shown  that  in  injiu'ies  to  the  carotid  arteries,  progres- 
sive thrombosis  is  quite  as  frequent  a  cause  of  cerebral  complications 
as  embolism. 

Lastly,  it  may  be  added  that  the  area  involved  by  jjurely  anjcmic 
gangrene  is  as  a  rule  limited  in  extent,  and  except  in  the  case  of  the 
popliteal  vessels  it  seldom  renders  the  sacrifice  of  a  large  part  of  a 
limb  necessary.  Speaking  generally,  the  idtimate  result  of  arterial 
injuries  may  be  said  to  be  better  in  the  lower  than  in  the  upper 
extremity,  mainly  in  consequence  of  the  large  proportion  of  uncom- 
plicated injuries  to  the  superficial  femoral  vessels.  The  ill  effect  of 
associated  injuries  to  the  nerves  is  most  striking  in  the  axillary  vessels, 
and  the  worst  results  of  purely  vascular  injiu'ies  are  seen  in  the  case 
of  the  popliteal  vessels. 

The  influence  exerted  on  the  incidence  of  gangrene  by  sinuil- 
taneous  occlusion  of  the  satellite  vein  when  an  artery  is  tied,  is  dealt 
with  in  the  next  chapter.  No  doubt  can  exist  that  the  introduction 
of  this  j^ractice  has  effected  a  material  decrease  in  the  proportion  of 
limbs  lost. 


97 


CHAPTER    VI. 

THE     GENERAL     LINES     OF     OPERATIVE     TREATMENT 

APPLICABLE     TO 

GUNSHOT     INJURIES     TO     THE     BLOOD-VESSELS. 

It  will  be  convenient  in  this  place  to  introduce  some  general  remarks 
upon  the  forms  of  operation,  and  their  technique,  which  are  suitable 
to  the  treatment  of  gunshot  injuries  of  the  blood-vessels,  and  their 
consequences,  since  these  remarks  will  be  applicable  to  any  of  the 
special  uses  of  the  procedures  to  be  mentioned  later. 

The  first  question  to  be  considered  is  the  form  of  provisional 
control  of  the  local  circulation  during  the  course  of  the  exploration 
necessary  for  the  location  of  the  actual  wound  of  the  vessel.  The 
wounded  man  may  come  under  observation  with  a  tourniquet  already 
applied  ;  but  if  this  has  been  properly  placed  it  probably  encroaches 
too  nearly  on  the  field  of  operation,  and  will  need  to  be  reapplied  if 
it  be  decided  to  make  use  of  this  form  of  aid. 

The  objection  raised  to  the  rubber- tube  tourniquet,  that  it  encour- 
ages parenchymatous  bleeding  after  its  removal  from  the  limb,  cannot 
be  gainsaid.  Yet  the  subsequent  application  of  a  bandage  to  the 
limb  meets  this  difficulty  in  great  measure  ;  and  if  the  Esmarch's 
bandage  be  not  employed,  and  the  arterioles  and  capillaries  have  not 
been  completely  emptied,  the  objection  becomes  of  little  importance. 
A  justifiable  practical  objection  which  may  be  raised  to  its  use  lies 
in  the  experience  that  it  is  often  desirable  to  release  the  control  in 
order  to  obtain  an  indication  of  the  exact  source  of  the  bleeding,  and 
whether  it  emanates  from  one  point  alone.  In  this  respect  the  tour- 
niquet is  inconvenient.  With  full  appreciation  of  the  disadvantages 
which  accompany  its  use,  I  still  think  that  the  india-rubber  tourniquet 
furnishes  the  readiest  and  most  generally  serviceable  form  of  pro- 
visional control  of  the  circulation  when  applicable,  as  is  the  case  in 
a  large  proportion  of  the  injuries  to  the  large  blood-vessels  of  the 
limbs. 

When  a  tourniquet  is  impossible,  as  in  the  case  of  ^vounds  of  the 
neck  or  of  the  limbs  close  to  the  trunk,  a  provisional  ligature  may  be 
placed  on  the  main  vessel  on  the  proximal  side  of  the  injur^^  As  a 
rule,  the  incision  for  the  main  operation  should  be  sufficiently  extensive 
to  give  access  to  the  point  or  points  at  which  it  is  desired  to  establish 
the  provisional  control.     The  subclavian  artery  at  the  root  of  the  neck, 


98        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

and  tlie  external  iliac  arteries,  form  perhaps  the  only  exceptions  to 
observance  of  this  rule  ;  in  both  these  instances  a  separate  incision 
possesses  manifest  advantages. 

Mention  of  the  occasional  troubles  attendant  on  adoption  of  the 
procedure  of  provisional  ligature  is  necessary,  since  in  my  opinion  they 
provide  sufficient  grounds  for  not  considering  it  a  measure  suitable  for 
routine  application.  Putting  on  one  side  the  minor  objection  that  it 
may  be  necessary  to  make  an  additional  womid  (although  under  some 
circumstances  this  drawback  may  be  a  very  real  one),  other  objections 
may  be  raised.  The  chief  of  these  lies  in  the  danger  of  creating  a  local 
weakening  of  the  vitality  of  the  arterial  wall  as  a  direct  result  of  the 
constriction  of  the  vessel ;  this  may  amount  to  actual  tissue  damage 
if  the  loop  be  drawn  too  tightly  or  be  maintained  too  long  in  position. 
Under  these  circumstances  thrombosis  may  develop  at  the  weakened 
spot,  or  if  the  wound  should  become  accidentally  infected,  secondary 
ha?morrhage  may  be  favoured.  Both  these  unfortunate  results  have 
come  under  my  observation. 

It  must  always  be  borne  in  mind,  therefore,  that  delicacy  is  of  the 
greatest  importance  in  the  aj)plication  of  the  method,  and  various 
plans  of  avoiding  the  dangers  of  unnecessary  tightening  of  the  ligature 
may  be  mentioned.  The  simplest  is  not  to  knot  the  ligature,  but  to 
use  the  thread  merely  as  a  loop  to  raise  the  vessel  from  its  bed,  which 
act  generally  suffices  to  control  the  circulation  through  the  vessel.  The 
weak  point  in  this  method  lies  in  the  fact  that  the  surgeon  then  becomes 
dependent  on  his  assistant  for  the  delicacy  and  efficiency  of  the  trac- 
tion maintained,  and  if  the  assistance  be  limited  to  one  person,  a  part 
of  whose  thoughts  are  claimed  by  other  details  of  the  operation,  it  may 
be  difficult  for  him  to  devote  constant  attention  to  this  point.  A 
second  plan  is  to  apply  an  arterial  clamp  ;  this  instrument  is  available 
in  several  patterns,  and  is  often  useful ;  it  requires  sometimes,  how- 
ever, to  be  applied  in  situations  where  it  cannot  be  readily  kept  in 
position  without  constant  attention,  and  this  trouble  is  aggravated  by 
the  fact  that  it  can  only  be  applied  loosely,  and  is  apt  to  slip  out  of 
position  unless  continuously  held. 

I  have  found  a  method  first  introduced  to  my  notice  by  Colonel 
Gordon  Watson  the  most  satisfactory.  This  consists  in  passing  a 
piece  of  narrow  tape,  or,  if  this  is  not  forthcoming,  a  thick,  smooth 
ligature,  beneath  the  vessel,  and  knotting  it  by  a  single  surgical  turn 
over  a  piece  of  drainage  tube  of  about  the  same  calibre  as  the  artery, 
placed  upon  its  siu'face.  By  this  method  a  soft  clastic  form  of  com- 
pression is  obtained.  Hence  the  walls  of  the  vessel  run  less  risk  of 
injury,  from  the  facts  that  the  ligatiu'c  is  wide,  and  the  knot  (always 
the  most  dangerous  point)  is  made  over  the  rubber  tube  and  not  on  the 
vessel  itself. 


GENERAL    LINES    OF    OPERATIVE    TREATMENT       99 

We  may  now  turn  to  the  ineisions,  and  it  must  be  pointed  out 
that  these  need  to  be  planned  upon  a  much  wider  scale  than  is  the 
case  with  the  classical  operations  so  well  known  to  the  student  of 
operative  surgery.  The  latter  have  been  so  devised  as  to  allow  the 
artery  to  be  secured  at  the  '  seat  of  election '  with  the  least  amount  of 
damage  to  the  body.  The  military  surgeon  is  able  to  concern  himself 
little  with  such  operations  and  the  theory  upon  which  they  have  been 
planned,  except  in  so  far  as  their  study  and  apjolication  has  familiarized 
him  with  the  anatomical  details  which  still  form  his  chief  guide. 

Exploratory  incisions  need  to  be  free  for  more  than  one  reason. 
The  operations  as  a  rule  need  to  be  completed  in  the  shortest  time 
compatible  with  efficiency,  and  the  surgeon  has  to  work  under  very 
special  conditions.  The  wounded  man  may  be  already  suffering  from 
considerable  loss  of  blood  ;  the  exact  location  of  the  wound  in  the  course 
of  the  artery  may  be  doubtful — indeed,  it  may  happen  that  when  the 
surgeon  sets  out  to  deal  with  an  injury  of  the  main  trunk,  exploration 
may  show  that  the  actual  source  of  haemorrhage  is  in  a  branch  only  ; 
or,  again,  there  may  be  more  than  one  lesion  in  the  main  trunk,  or  more 
than  one  branch  may  need  to  be  dealt  with.  In  other  cases  the  course 
taken  by  the  missile  may  have  so  nearly  corresponded  with  that  of  the 
artery  that  extensive  loss  of  substance  has  been  effected,  and  the  two 
extremities  of  the  vessel  may  be  widely  separated.  Added  to  these 
difficulties,  the  vessel,  if  a  mobile  one,  may  have  become  greatly  dis- 
placed from  its  normal  course,  extravasated  blood  having  pushed  it 
over  in  the  direction  of  least  resistance.  Normal  landmarks,  such  as 
nerves,  may  have  been  divided  ;  portions  of  them  may  have  been  shot 
away,  or  they  may  have  been  considerably  displaced  from  their  normal 
position.  Injury  to  the  satellite  veins,  or  others,  may  greatly  aggravate 
the  difficulty  of  stilling  haemorrhage  and  pursuing  the  search  for  the 
wounded  artery  imder  comfortable  conditions.  The  infiltration  of 
the  tissues  generally  with  extravasated  blood  often  renders  structures 
difficult  of  recognition  and  troublesome  to  deal  with,  in  every  part  of 
the  field  of  operation.  Lastly,  the  lesion  may  be  so  situated  anatomi- 
cally as  to  be  in  the  most  inconvenient  and  inaccessible  segment  of  the 
course  of  the  artery  as  far  as  the  surgeon  is  concerned.  This  list  of 
difficulties,  if  not  exhaustive — and  it  takes  no  account  of  paucity  of 
assistance,  and  possible  deficiencies  in  the  conditions  suitable  for  a 
troublesome  operation — offers  at  any  rate  sufficient  explanation  of  the 
necessity  for  a  wide  exploratory  incision. 

All  these  difficulties,  moreover,  tend  to  be  exaggerated  if  the  case 
comes  under  treatment  more  than  twenty -four  to  thirty-six  hours  after 
the  injury.  The  tissues  are  then  already  stiffened  and  oedematous 
generally  ;  the  same  condition  is  met  with  in  the  wall  of  the  artery  itself, 
and  the  vessel  has  become  fixed  and  immobile  in  its  sheath. 


100      CWNSHOT    IN  J  V  HIES    TO    THE    BLOOD-VESSELS 

When  the  field  of  operation  has  been  freely  laid  open,  the  first  step 
consists  in  clearing  it  of  extravasated  blood  and  blood-clot.  Whether 
a  tourniquet  or  a  provisional  ligature  has  been  applied,  it  may  now 
become  necessary  to  apply  ligatures  to  bleeding  veins.  It  is  sometimes 
useful  to  have  a  second  tourniquet  placed  in  position  on  the  distal  side 
of  the  woxmd,  which  can  then  be  tightened  up  when  required,  shoidd 
venous  h;rmorrhage  from  the  distal  direction  be  free. 

A  portion  of  the  blood  will  be  fluid,  but  that  in  contact  with  the 
walls  of  the  cavity  will  have  already  coagulated  and  formed  more  or 
less  firm  connections,  as  a  result  of  infiltration  of  the  surrounding  con- 
nective tissue.  When  the  blood  and  clot  have  been  removed,  it  will 
be  found  necessary  in  some  cases  to  cleanse  the  wound  mechanically 
by  removing  badly  damaged  and  possibly  infected  tissue  in  the  line 
traversed  by  the  missile.  If  this  be  considered  needful,  it  should  be 
carried  out  at  this  stage,  so  as  to  obviate  diffusion  of  infection  to  the 
large  exposed  surface  of  the  tissues. 

The  search  for  the  wounded  spot  in  the  vessel  is  now  commenced, 
bearing  in  mind  the  possible  displacement  of  the  artery  from  its  normal 
course  in  the  direction  of  least  resistance  ;  that  this  displacement  will 
probably  be  away  from  the  bone,  and  that  the  vessel  is  more  likely  to 
be  in  the  side  of  the  wound,  or  more  superficial  than  normal  rather  than 
pressed  backwards.  If  the  lesion  be  a  lateral  wound  of  some  size,  it 
will  often  be  seen  readily,  the  white  inner  lining  of  the  artery  showing 
up  strongly  through  the  gap  in  the  wall.  If  the  lesion  is  in  a  deep,  not 
readily  inspected  position,  the  gap  may  often  be  easily  felt,  the  tiji 
of  the  finger  detecting  the  firm  ring  formed  by  the  margins  of  the  defect 
and  the  resistant  smooth  floor  afforded  by  the  opposite  wall  of  the 
vessel.  If  no  lesion  of  the  main  trunk  be  detected,  a  search  should  be 
made  in  the  line  of  the  course  of  the  principal  branches,  and  if  difficulty 
arises  even  yet  in  locating  the  wounded  spot,  the  tourniquet  or  provi- 
sional ligature  must  be  cautiously  loosened,  and  the  point  or  points 
observed  from  which  blood  commences  to  flow. 

The  wounded  vessel  may  now  be  ligatured  on  either  side  of  the 
opening  and  completely  divided.  Careful  search  should  now  be  made 
to  be  certain  that  no  branch  is  taking  origin  from  the  excluded  segment 
of  the  vessel,  as  this  may  be  a  source  of  recurrent  or  secondary  hfcmor- 
rhage  if  not  occluded.  The  origin  of  branches  in  such  a  position  is  not 
unconuiion,  and  as  we  have  already  seen,  fixation  by  one  of  its  own 
branches  often  accounts  for  the  involvement  of  the  walls  of  the  vessel. 
Division  of  the  narrow  strand  connecting  the  tAvo  open  ends  of  the 
vessel  in  extensive  lateral  wounds  is  particularly  important,  in  order 
to  allow  of  full  retraction. 

A  word  should  be  added  as  to  the  inadvisability  of  hastily  placing 
a  proximal  ligature  on  the  artery  before  the  bleeding  point  has  been 


GENERAL    LINES    OE    OPERATIVE    TREATMENT     101 

located  exactly.  In  certain  positions  where  a  number  of  small 
branches  arise  (e.g.,  common  femoral  artery),  the  free  flow  of  blood 
may  apparently  indicate  a  lateral  wound  of  the  trunk  ;  but  after  the 
main  trunk  has  been  tied  and  all  is  clear,  it  may  prove  that  the 
injury  was  after  all  of  one  of  the  small  branches  in  close  proximity 
to  its  origin,  and  the  main  vessel  has  been  needlessly  sacrificed. 

SHOULD   BOTH   ARTERY   AND   VEIN    BE    OCCLUDED  ? 

In  preparing  a  former  contribution  to  the  surgery  of  wounded 
arteries,*  I  was  much  struck  by  the  observation  that  proximal  liga- 
ture of  the  femoral  artery  in  cases  of  arterio-venous  aneurysm  was 
followed  in  a  large  proportion  of  instances  hj  gangrene  of  the  limb, 
while  excision  of  the  implicated  segments  of  both  artery  and  vein  gave 
consistently  good  results.  An  explanation  of  this  apparent  incon- 
sistency wall  be  found  below,  as  also  further  considerations  which 
led  me  to  conclude  that  when  an  artery  needs  to  be  tied,  the  satellite 
vein  should  be  occluded  also. 

It  is  to  be  regretted  that  John  Hunter  himself  did  not  write  the 
paper  describing  his  operation  of  proximal  ligature  and  the  grounds 
upon  which  he  was  led  to  undertake  it.  In  at  least  one  of  the  eases 
described  in  the  paper  by  Sir  Everard  Home,f  possibly  in  the  first  three, 
both  the  femoral  artery  and  vein  were  included  in  the  ligature  ;  in  the 
fourth  we  are  definitely  told  that  the  artery  only  was  included.  From 
that  period  onwards  surgical  opinion  has  been  definitely  to  the  effect 
that  the  greatest  care  should  be  taken,  when  occluding  a  main  artery,  to 
avoid  all  injury  to  the  vein.  In  fact,  every  operation  for  the  ligature 
of  an  artery  has  been  so  devised  that  the  aneurysm  needle  is  passed  in 
a  direction  away  from  the  vein  in  order  to  minimize  the  risk  of  injurj^ 
to  that  vessel,  not  alone  to  avoid  the  technical  inconvenience  of 
immediate  liEcmorrhage,  but  also  with  the  definite  object  of  preserving 
the  venous  circulation  intact. 

Observation  of  a  large  number  of  coincident  wounds  of  large 
arteries  and  veins  has  in  no  way  endorsed  the  view  that  simultaneous 
occlusion  of  both  artery  and  vein  exercises  any  deleterious  influence  on 
the  subsequent  collateral  arterial  circulation  and  the  vitality  of  the 
limb.  In  support  of  this  statement  a  few  examples  illustrating  the 
innocuous  nature  of  operations  for  the  occlusion  of  veins  in  general  may 
be  first  given.  Operations  for  the  cure  of  varicose  veins  have  demon- 
strated the  ease  with  which  a  compensatory  balance  is  attained  when 
the  blood  is  diverted  from  the  larger  channels.     Occlusion  of  the  internal 


*  Bradshaw  Lecture,  1913. 

f  John  Hunter's   Works.     Palmer's  edition,  vol.   iii,  p.    604. 


102      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

jugular  and  other  large  venous  triuiks  effected  in  order  to  prevent  the 
diffusion  of  septic  emboli  has  not  given  rise  to  obvious  permanent 
trouble.  As  is  well  known  also,  occlusion  even  of  the  vena  cava  by 
surgical  methods  has  been  survived,  and  the  capacity  of  the  venous 
circulation  to  maintain  itself  by  compensatory  changes,  which  is  seen 
when  this  vessel  imdergoes  obstruction  by  thrombosis,  is  a  familiar 
experience. 

In  a  very  considerable  proportion  of  gunshot  injuries  to  large 
arterial  trunks  the  neighbouring  vein  is  contused  and  becomes  throm- 
bosed, and  this  has  not  been  shown  to  give  rise  to  increased  risk  of 
gangrene  of  the  limbs.  Ligature  of  the  common  carotid  artery  together 
with  the  internal  jugular  vein  en  masse  has  been  performed  in  cases  of 
emergency  without  increased  risk  of  the  development  of  the  cerebral 
anaemia  and  softening  so  often  a  consequence  of  ligature  of  the  artery 
alone.  Further,  where  simultaneous  ligature  of  both  artery  and  vein 
in  other  parts  of  the  body  has  been  obligatory  on  account  of  woimds 
of  both  vessels,  untoward  events  have  not  been  observed. 

Evidence  exists,  moreover,  that  under  certain  conditions  simultan- 
eous occlusion  of  both  artery  and  vein  is  a  preferable  procedure.  The 
first  example,  not  an  unmixed  or  simple  one,  may  be  sought  in  the 
results  observed  to  follow  the  aj^plication  of  a  single  proximal  ligature 
to  the  artery  in  cases  of  arterio-venous  aneurysm  or  aneurysmal  varices 
of  the  femoral  vessels.  In  patients  so  treated  during  the  South  African 
War,*  gangrene  of  the  limb  followed  in  more  than  50  per  cent  of 
the  cases.  The  frequency  of  this  accident  finds  a  simple  explanation 
if  we  consider  what  actually  results  from  the  operation.  The  main 
vessel  being  occluded  and  the  direct  arterial  pressure  from  behind 
being  abolished,  blood  which  has  been  carried  by  the  arterial  collaterals 
to  the  distal  portion  of  the  injured  trunk,  instead  of  passing  to  the 
peripheral  circulation,  takes  the  course  of  least  resistance  backwards 
into  the  vein  through  the  arterio-venous  communication,  and  thus  the 
limb  practically  bleeds  to  death  much  in  the  same  way  as  if  the  distal 
end  of  the  wounded  artery  opened  on  the  surface  of  the  limb.  Hence 
the  comparative  safety  of  removal  of  the  communication  en  masse  and 
occlusion  of  all  four  openings  by  ligature  which  has  been  confirmed  by 
numerous  operations  during  the  present  war. 

A  more  striking  example  is  offered  by  the  result  of  ligaturing  the 
popliteal  vein  alone  for  the  treatment  of  senile  gangrene  of  the  foot. 
W,  A.  Oppel,")"  ascribing  the  good  results  occasionally  observed  to  follow 
arterio-venous  anastomosis  for  the  cure  of  this  condition  to  control  of 


*  Surgeon-General,  W.   F.  Stevenson,  Report  on  the  Surgical  Cases  noted 
in  the  South  African  War,  1899-1902. 

■f  Zentralblatt  fiir  Chirurgie,  1913,  No.  31,  p.   1241. 


GENERAL    LINES    OF    OPERATIVE    TREATMENT     lO.'i 

the  venous  circulation  and  consequent  rise  in  the  blood-ijressiire  oi'  the 
Hmb,  was  led  to  substitute  simple  occlusion  of  the  popliteal  vein  to 
produce  the  same  effects.  In  six  cases  thus  treated  the  extremities 
were  seen  to  recover  not  only  their  warmth  and  colour  without  the 
development  of  oedema,  but  also  a  certain  degree  of  hyperscmia  of  the 
feet  and  toes. 

On  these  and  other  grounds  it  must  be  admitted  that  the  balance 
of  the  collateral  circulation  is  likely  to  be  more  efficiently  maintained 
if  the  vessels  which  carry  it  on  more  nearly  correspond  in  size  and  conse- 
quent equality  in  the  blood-pressure  and  rate  of  flow.  The  elimination, 
in  fact,  of  the  capacious  main  vein  is  a  real  advantage,  since  this  for 
the  time  affords  a  too  ready  channel  of  exit  for  the  diminished  arterial 
supply,  as  well  as  an  undesirable  reservoir  for  stagnation. 

These  considerations  have  led  me  not  only  to  regard  obligatory 
simultaneous  occlusion  of  a  main  artery  and  vein  as  a  negligible 
factor  in  the  risk  of  gangrene  of  a  limb  ;  but  to  hold  further,  that  the 
procedure  is  preferable  whether  the  vein  be  wounded  or  not ;  the  result 
of  the  combined  procedure  being  to  maintain  within  the  limb  for  a 
longer  period  the  smaller  amount  of  blood  supplied  by  the  collateral 
arterial  circulation,  and  hence  to  improve  the  conditions  necessary 
for  the  preservation  of  the  vitality  of  the  limb.* 

M.  van  Kend  tested  the  accuracy  of  the  above  conclusions  as  to 
the  rise  of  blood-pressure  at  the  laboratory  of  the  Ocean  Ambulance 
at  La  Panne  by  some  experiments  on  animals,  and  made  the  following- 
remarks  in  his  observations  at  the  Inter-allied  Conference  of  Surgeons 
held  in  Paris  in  May,  1917  : — 

"  In  carrying  out  a  series  of  experiments  made  with  the  object 
of  determining  the  indications  and  the  physiological  basis  for  trans- 
fusion of  blood,  I  have  had  the  opportunity  of  measuring  the  blood- 
pressure  in  limbs  of  which  the  main  artery  had  been  ligatured.  The 
blood-pressure  was  taken  successively  after  the  artery  alone  had  been 
tied,  and  again  when  ligatvu'e  of  the  vein  had  been  superadded.  My 
observations  confirm  the  view  that  has  been  expressed  by  Sir  George 
Makins  ;  in  fact,  plethysmographic  tracings  demonstrate  clearly  that 
a  slight  rise  in  the  blood-pressure  in  the  limb  follows  the  application 
of  a  ligature  to  a  main  vein,  after  previous  ligature  of  the  artery. 

"  It  appears,  then,  from  the  standpoint  of  the  physiologist,  that 
to  leave  the  main  vein  viable  after  occlusion  of  the  main  artery  of  a 
limb,  diminishes  what  may  be  called  the  residuary  blood-pressure 
maintained  by  the  collateral  circulation.  If  the  contribution  of  the 
collateral  circulation  is  allowed  to  remain  with  the  main  vein  intact,  it 


Hunterian  Oration,  Lancet,  Vol.  i,   1917,  Feb.  17,  p.   249. 


104      GUNSHOT    INJUIUES    TO    THE    BLOOD-VESSELS 

is  natural  that  the  residuary  hlood-pressure  should  fall.  If  this  view 
be  adojited,  ligature  of  the  vein  as  well  as  the  artery  should  be  recom- 
mended in  order  to  retain  the  blood  supplied  in  longer  contact  with  the 
tissues.  Thus  the  most  satisfactory  conditions  for  the  maintenance 
of  the  nutrition  of  the  organs  are  provided,  because  the  obstacle  to  the 
retiu-n  circulation  provided  by  ligature  of  the  vein  retains  the  blood 
for  a  longer  period  in  the  member." 

After  discussion  of  the  question  at  the  meeting,  the  following- 
conclusion  was  adopted  :  "  Contrary  to  what  has  imtil  now  been 
believed,  simultaneous  ligature  of  both  artery  and  vein  when  both 
vessels  have  been  Avounded  does  not  give  rise  to  increased  risks  of 
gangrene  ;  in  fact  it  diminishes  them.  Facts  tend  to  prove,  even  when 
the  wound  is  limited  to  the  artery,  that  simultaneous  occlusion  of  the 
un wounded  vein  is  to  be  recommended."  * 

The  numbers  given  below  were  submitted  to  the  same  meeting  ; 
these  were  collected  on  observations  of  my  own,  which  included  every 
case  of  the  kind  operated  upon  during  a  period  of  two  years  in  the 
district  in  which  I  worked.  It  is  obvious  that  the  incidence  is  abnor- 
mally high,  but  this  was  certainly  the  case  during  the  years  1915-16. 

Comparative  Result  of  Ligaturing  Artery  alone,  and  Simul- 
taneous Ligature  of  Artery  and  Vein. 


jS'o.  of 
cases 

Artery  alone 

N"o.  of 
cases 

Artery  and  Vein 

Grood  result 

G-angrene     | 

Good 
result 

G-angrene 

Subclavian 

Axillary 

Brachial 

Femoral 

Popliteal 

Tibial     .  . 

Carotid    .  . 

4 

6 

13 

32 

24 
4 

18 

3 

5 

10 

24 

14 

4 

12 

■  1 
1 
3 
8 

10 

6 

1 

4 

1 

32 

28 
1 
4 

1 
4 
1 
25 
22 
1 
3 

7 
6 

1 

Totals 

101 

72 

29 

28  per  cent 

71 

57 

14 

19-7  per  cent 

Every  effort  was  made  to  exclude  any  instances  in  which  the  gangrene 
was  due  to  anaerobic  infection,  and  it  must  be  imderstood  that  the 
table  does  not  generally  imply  gangrene  en  masse  of  the  limbs,  but  in 
many  cases  a  very  limited  amount  confined  to  digits  or  patches  of  skin. 


*  Comptes  Rendus,  Conf.  Chir.  luteralL,  Paris,  1917,  p.  348. 


GENERAL    LINES    OF    OPERATIVE    TREATMENT     105 

Further  statistics  on  this  svibjcct  will  be  found  in  the  sections 
devoted  to  the  special  vessels  ;  but  they  are  of  less  value  because, 
since  the  middle  of  1917,  the  practice  in  France  has  been  generally 
in  favour  of  simultaneous  ligature  of  both  vessels. 

Major  Hamilton  Drummond  has  kindly  furnished  me  with  a  note 
regarding  some  investigations  which  he  made  on  this  subject  in  the 
ease  of  the  visceral  vessels.  Loops  of  the  small  intestine  of  the  cat, 
and  of  the  colon  of  the  Belgian  hare,  were  made  use  of.  After  a  care- 
ful study  made  by  means  of  barium  injections  and  a;-ray  photographs 


,^.pj^»Va>t'  V-& 


Fig.  31. — Portion  of  small  intestine  of  a  eat.  The  segment  between  2  and  3  has 
been  treated  by  ligature  of  arteries  and  veins  in  the  mesentery.  The  gut  on  examination 
48  hours  later  showed  some  blue  discoloration,  but  contracted  normally  and  was  quite 
free  from  gangrene.  The  bowel  between  3  and  4  is  normal.  The  portion  between 
4  and  5  has  been  treated  by  ligature  of  the  arteries  only,  the  venous  supply  being  left 
intact  ;  it  shows  a  patch  of  gangrene  1  in.  in  length.  Each  devascularized  group  is 
4-J-  in.  in  length.      Major  Hamilton  Drummond. 


to  determine  the  number  of  vessels  which  should  be  ligatured  in  order 
to  avoid  error  from  leaving  too  free  an  anastomotic  supply,  the  follow- 
ing experiment  was  made  six  times  on  cats'  intestine  {Fig.  31). 

"  A  loop  of  ileum  towards  the  csecal  end  was  drawn  out  of  the 
abdomen,  and  the  arteries  and  veins  supplying  about  five  inches  of 
the  gut  w^ere  ligatured,  cutting  off  the  total  macroscopical  blood- 
supply  to  that  portion.  The  loop  was  returned  into  the  abdomen, 
and  a  second  loop  about  six  inches  higher  w^as  delivered  and  devas- 
cularized by  ligature  of  the  arterj^  alone. 


lOG     GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

"  Of  six  experiments  performed  upon  the  cat,  in  three  a  definite 
rino'  of  ganorene  developed  in  the  middle  of  the  segment  of  bowel 
which  had  been  depri^^ed  of  its  arterial  sn])ply  alone,  while  the 
segment  treated  by  simultaneous  ligature  of  artery  and  vein  showed 
little  or  no  change.  In  one  case  where  the  animal  was  killed  while 
still  looking  in  good  health,  twenty-four  hoiu's  after  ligature  of  the 
vessels,  the  segment  treated  by  ligature  of  the  arteries  only,  showed 
more  serious  changes  than  the  segment  treated  by  simidtaneous 
ligature  of  artery  and  vein.  Of  the  remaining  two  cases,  one  showed 
no  change  at  all,  consequent  upon  the  fact  that  too  short  a  segment 
of  the  bowel  had  been  deprived  of  its  blood-supply,  while  the  result 
in  the  sixth  case  was  complicated  by  the  development  of  an  acute 
volvulus." 

ANGEIORRHAPHY. 

Suture  of  wounded  vessels,  the  ideal  method  of  dealing  with 
the  injuries,  has  been  widely  advocated,  and  a  large  number  of 
these  operations  have  been  performed  The  largest  numerical  series 
are  those  recorded  by  Soubbotitch  and  Bier  ;  the  latter  reported 
upon  no  less  than  100  cases  as  early  as  Easter,  1915,  As  far  as 
my  own  experience  goes,  so  many  operations  have  not  been  per- 
formed by  any  individual  surgeon  in  the  British  service.  Wound 
conditions  in  the  early  part  of  the  campaign  were  not  favourable  to 
the  performance  of  arteriorrhaphy,  and  only  a  few  tentative  operations 
were  performed,  after  the  experience  of  which,  most  British  surgeons 
returned  to  the  simpler  procedure  of  ligature.  Such  operations  as 
were  still  performed,  moreover,  were  usually  undertaken  after  the 
lapse  of  some  days  from  the  receipt  of  the  original  injury,  when 
general  infiltration  and  consequent  stiffening  of  the  walls  of  the  vessels 
made  the  technique  particularly  difficult.  The  technical  difficulties 
were  further  increased  by  the  use  of  extremely  fine  needles  and  thin 
silk,  such  as  had  been  used  by  Dr.  Carrel  for  his  experimental  work 
on  animals,  or  by  the  opposite  conditions  in  which  silk  or  catgut  of 
too  coarse  a  calibre  was  employed. 

During  the  past  two  years — 1917-18 — considerable  change  has 
taken  place  in  these  conditions.  Earlier  operations  have  been  imder- 
taken  ;  and  it  has  been  realized  that  fine  silk,  such  as  Japanese  0000, 
and  needles  of  a  corresponding  size,  are  fine  enough  for  the  piu'pose 
required,  that  they  meet  the  difficidty  of  dealing  with  stiffened  vessels, 
and  are  far  more  readily  and  easily  manipulated. 

Beyond  this,  experience  has  been  gained  as  to  the  particular 
vessels,  and  to  the  nature  of  the  wounds,  most  suited  to  this  form  of 
treatment.  The  indications  for  primary  sutin-e  of  the  vessels  may 
be  shortly  summarized  as  follows  : — 


GENERAL    LINES    OF    OPERATIVE    TREATMENT     107 

1.  An  accompanying  wound  of  the  soft  parts  which  there  is  a 
reasonable  probability  of  maintaining  in  an  aseptic  condition. 

(Suture  of  vessels  in  connection  with  arterial  ha;matomata  or 
aneurysms  is  dealt  with  on  p.  85.) 

2.  Wounds  of  moderate  dimensions,  exhibiting  as  far  as  possible 
an  incised  or  mildly  lacerated  character.  The  most  favourable  are 
those  produced  by  sharp  fragments  of  metal,  and  of  these  the  most 
suitable  to  suture  are  the  longitudinal,  traversing  perforations  with 
not  too  great  a  loss  of  substance  ;  and  lateral  wounds,  generally  not 
involving  more  than  half  the  circumference  of  the  vessel. 

Many  bullet  injuries  also  form  favourable  subjects  for  treatment 
by  suture,  but  in  the  early  stages  it  is  often  difficult  to  estimate  the 
degree  of  contvision  which  accompanies  the  actual  wound. 

3.  More  extensive  injuries  can  only  be  treated  by  excision  of  the 
damaged  ends  of  the  vessel,  followed  by  a  complete  circular  union. 
With  a  highly  developed  technique,  reunion  of  the  ends  of  the  severed 
vessel  offers  no  immediate  difficulties,  and  the  opportunity  afforded 
of  ensuring  tissue  which  has  not  suffered  contusion  is  an  important 
element  in  final  success.  On  the  other  hand,  the  line  of  union  is 
necessarily  exposed  to  considerable  tension,  and  the  limb  needs  to 
be  placed  in  a  forced  position  to  overcome  this  obstacle  to  union 
as  far  as  possible.  This  question  of  position  renders  transport  more 
difficult,  and  prolonged  assumption  of  a  flexed  position  may  also 
be  followed  by  great  difficulty  in  straightening  the  limb  eventually. 
Again,  inobilization  of  the  vessel  needs  to  be  very  free,  and  this 
necessitates  an  amount  of  dissection  of  the  limb  which  is  often 
undesirable.  All  these  conditions  need  to  be  taken  into  considera- 
tion in  deciding  upon  establishing  a  circular  union.  The  most 
promising  arteries  for  this  procedure  are  the  carotid,  the  brachial, 
and  the  superficial  femoral,  in  which  three  vessels  not  only  long- 
stretches  are  assured,  but  also  stretches  which  may  be  free  from 
any  fixation  by  branches. 

4.  With  regard  to  the  arteries  suture  of  which  is  most  strongly 
called  for — as  far  as  the  question  of  ultimate  maintenance  of  the 
vitality  of  the  limb  at  a  high  level  is  concerned — two  or  three  vessels 
stand  out  prominently. 

The  common  carotid,  the  external  iliac,  and  its  continuation  the 
common  femoral,  may  be  first  considered.  Fortunately,  in  the  case  of 
both  these  trunks,  the  importance  of  their  peripheral  distribution, 
and  their  comparative  accessibility  and  capacity  for  the  necessary 
mobilization,  are  in  consonance.  To  a  lesser  degree  the  same  may  be 
said  about  the  main  trunk  of  the  upper  limb  ;  but  it  cannot  be  said 
that  the  axillary  is  a  really  satisfactory  vessel  to  deal  with,  on  account 
of  its  depth  of  position,  the  important  muscles  which  require  division 


108     GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

to  oain  the  needful  exposure,  and  the  difficulties  often  arising  in  dealing- 
with  the  veins. 

5.  Suture  of  the  veins  is  an  easier  matter  in  almost  any  position, 
and  as  far  as  the  control  of  ha?morrhage  is  concerned,  it  ma}^  be  said 
to  be  generally  successful. 

With  regard  to  the  sin-gical  technique  of  these  operations,  I  do 
not  think  any  material  modification  of  the  method  of  Carrel,  beyond 
the  use  of  somewhat  larger  silk  and  needles,  can  be  called  for.  In 
effecting  circular  unions,  it  has  been  shown  that  two  fixation  threads 
are  sufficient ;  otherwise  I  consider  that  the  main  aim  of  those 
practising  arterial  surgery  should  be  to  strive  to  approach  the  excel- 
lence attained  by  the  master  of  this  method, 

A  remark  has  already  been  made  as  to  the  unsatisfactory  results 
which  may  follow  plication  as  a  means  of  obliterating  the  cavity  of 
small  aneurysmal  sacs,  and  of  the  employment  of  flaps  fashioned 
from  the  Avail  of  the  sac  for  the  jaurpose  of  reconstructing  an  artery. 
It  would,  after  all,  appear  to  be  obvious  that  a  flap  containing  neither 
muscular  nor  elastic  tissue  can  hardly  be  regarded  as  satisfactory 
material  for  repairing  an  arterial  defect.  Such  flaps,  moreover,  not 
only  lack  the  power  of  active  contraction  and  elasticity,  but  also, 
as  consisting  of  cicatricial  tissue,  are  liable  to  subsequent  contraction 
or  they  may  prove  of  insufficient  resisting  capacity  to  withstand 
the  force  of  the  circulation.  These  criticisms  also  apply  to  the  em- 
ployment of  fascial  flaps  for  strengthening  weak  unions ;  in  most 
instances  the  subsequent  fate  of  a  vessel  repaired  by  this  method 
will  probably  be  contraction  and  occlusion. 

As  to  the  general  results  attained  by  the  method  of  suture  in 
the  series  of  cases  under  consideration,  reference  may  be  made  to 
the  sections  devoted  to  the  individual  arteries.  I  think  these  results 
may  be  regarded  as  demonstrating  that  the  method  of  suture  is  not 
so  difficult  of  practical  application  as  has  been  sometimes  assumed  ; 
further,  that  the  ultimate  results  may  be  claimed  to  be  superior  to 
those  to  be  obtained  by  simple  ligature  of  the  vessels. 

It  cannot,  however,  be  said  that  ideal  results  are  common,  since 
experience  has  shown  that  either  early  thrombosis,  or  later  cicatricial 
contraction,  may  after  all  lead  to  occlusion  of  the  artery.  Early 
thrombosis  may  reasonably  be  ascribed  in  most  cases  either  to 
defective  surgical  technique  or  to  the  choice  of  imsuitable  cases. 
Ultimate  occlusion  taking  place  at  a  later  date  is  probably  beyond 
the  power  of  the  siu'geon  to  avoid.  It  is  disappointing  as  vitiating 
his  principal  aim,  yet  the  great  advantage  of  a  gradual  cutting  off 
of  the  main  blood-stream  has  been  gained. 

A  word  may  be  added  as  to  the  course  which  should  be  taken 
by  the  surgeon  should   immediate  thrombosis  follow  the   closure  of 


GENERAL    LINES    OF    OPERATIVE    TREATMENT     109 

the  wound  in  the  wall  of  the  artery.  Under  these  eireumstances, 
perhaps  little  is  to  be  hoped  for,  but  I  believe  it  is  probably  wiser  not 
to  re-open  the  vessel  and  evacuate  the  clot,  which  will  probably 
be  rapidly  re-formed.  It  is  a  local  obstruction,  and  consists  of  a  soft 
thrombus,  probably  attached  firmly  only  along  the  actual  line  of 
suture,  and  caj^able  of  contraction  and  absorption.  Hence  it  is 
wiser  to  trust  to  these  possibilities. 

As  to  the  objection  concerning  the  length  of  time  needed  for  these 
operations,  it  is  obvious  that  a  decision  on  their  advisability  must 
be  determined  by  the  state  of  the  patient  and  the  judgement  of 
the  individual  surgeon. 

Suture  of  the  open  end  of  a  divided  vessel  is  often  preferable 
to  ligature,  as  it  avoids  any  stripping  up  of  the  vascular  cleft. 

THE     PROVISION     OF     A     TEMPORARY     CONDUIT     IN     PLACE     OF 
IMMEDIATE     OCCLUSION     OF     THE     VESSEL. 

No  doubt  can  exist  that  the  most  serious  of  the  effects  following 
abrupt  and  complete  obstruction  of  a  main  artery  depend  on  the 
sudden  anaemia  produced  in  the  area  of  the  peripheral  distribution. 
The  most  striking  example  of  immediate  effects  is  seen  when  the 
most  highly  organized  tissues,  as  those  of  the  central  nervous  system, 
are  included  in  the  area  rendered  anaemic.  Thus,  in  the  case  of  the 
carotid  artery,  a  sudden  hemiplegia  may  follow  obstruction  of  the 
main  blood-supply,  and  this  may  even  be  followed  by  a  fatal  issue 
in  as  short  a  period  as  thirty-six  hours  ;  or  permanent  or  a  merely 
temporary  paralysis  may  result. 

In  the  case  of  the  less  delicate  tissues  of  the  limbs,  the  onset  of 
the  signs  is  not  so  dramatically  demonstrated,  but  the  limb  may  at 
once  become  cold  and  functionless,  and  gangrene,  more  or  less  extensive, 
may  follow  in  a  couple  or  more  days. 

There  is  no  doubt  that  a  number  of  elements  combine  to  influence 
the  grade  of  local  vital  depression,  or  actual  death  of  the  parts,  induced 
by  abrupt  suppression  of  the  blood-supply.  Such  are  irregularities  in 
the  arrangement  of  the  normal  anastomoses  peculiar  to  the  individual ; 
the  common  interference  with  some  of  the  normal  channels  so  charac- 
teristic of  gunshot  woimds  ;  and,  more  rarely,  arterial  degeneration, 
although  this  last  is  not  often  present  in  the  young  and  healthy  adults 
who  form  so  large  a  proportion  of  the  military  class.  Then,  certain 
more  general  causes  may  be  contributory,  such  as  psychical  depression, 
exhaustion  from  exposure,  and  prolonged  exposure  to  cold  ;  and  lastly 
and  above  all,  the  recently  induced  severe  general  anaemia  and  fall 
of  blood-pressure  attendant  ujDon  a  large  haemorrhage. 


110     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

Any  or  all  of  these  influences  may  be  brought  to  bear  on  indi- 
viduals in  whom  no  preparatory  changes  in  the  circulation  have 
taken  placej  as  may  have  been  the  case  in  the  subjects  of  sponta- 
neous aneurysms,  or  of  tumours  which  have  exercised  a  slowly 
increasing  influence  on  the  calibre  of  the  main  vessel  of  supply.  As 
a  result,  we  find  gangrene  a  far  more  frequent  sequela  to  the  opera- 
tion of  ligatiu-e  than  we  should  have  primaril}^  expected  it  to  be. 

Again,  it  cannot  be  too  strongly  emphasized,  that  the  immense 
majority  of  the  cases  of  gangrene  which  have  been  observed  in  this 
war  followed  primary  or  intermediate  operations  of  urgency  ;  while 
the  incidence  after  operations  performed  at  a  later  date,  when  the 
dangers  dependent  on  primary  haemorrhage,  shock,  and  the  risks  of 
infection  have  passed  by,  has  been  almost  negligible. 

Dr.  Carrel  has  shown  many  years  ago  the  possibility  of  maintain- 
ing the  circulation  in  animals,  even  for  very  prolonged  periods,  by  the 
insertion  of  a  glass  junction  tube  into  the  ends  of  a  divided  artery. 
Professor  Tuffier  has  utilized  this  experience  by  introducing  a  similar 
procedure  in  the  treatment  of  wounded  arteries  in  man.  A  silver 
tube  is  made  use  of,  and  allowed  to  lie  in  position  until  it  has  evi- 
dently undergone  obstruction,  when  it  is  removed  and  the  ends  of  the 
vessel  are  secured  if  necessary.  The  silver  tube  is  previously  coated 
with  paraffin,  and  may  serve  to  maintain  a  gradually  decreasing 
stream  in  the  artery  for  from  a  few  hours  to  as  much  as  ten  days  ; 
during  this  period  the  interior  becomes  gradually  filled  with  laminated 
blood-clot.  Plate  IV  is  drawn  from  a  section  of  such  a  clot  removed 
from  the  interior  of  a  tube  which  had  lain  in  position  for  four  days. 
During  this  interval  time  is  afforded  for  progressive  enlargement  of 
the  collateral  branches  of  the  main  trunk,  and  thus  a  gradually 
increasing  strain  is  imposed  upon  the  compensatory  mechanism,  rather 
than  an  abrupt  and  complete  demand. 

These  tubes  have  been  widely  employed,  with  a  considerable 
measure  of  success.  In  two  cases  of  injury  to  the  popliteal  artery  in 
which  I  employed  the  tube,  in  neither  did  gangrene  supervene  ;  and 
I  have  seen  the  same  result  several  times  when  the  tube  has  been  used 
by  others.  A  striking  case  was  reported  to  me  in  which  the  com- 
pletely divided  femoral  artery  had  been  at  once  ligatured,  and  shortly 
afterwards  signs  of  incipient  gangrene  were  noted.  Captain  Cowell 
removed  the  ligatures  and  introduced  a  tube,  with  the  result  that 
gangrene  was  avoided.  In  one  instance  in  the  service  of  Professor 
Tuffier,  the  circulation  was  maintained  through  the  femoral  artery  for 
a  period  of  ten  days  ;  but  I  think  this  must  be  regarded  as  a  very 
exceptional  occurrence,  and  as  a  rule  the  tube  should  be  removed  at 
the  end  of  four  days,  and  at  this  date  I  have  always  found  it  occluded. 

The  main  element  in  procuring  success  in  using  these  tubes  lies 


PLATE     IV. 


Clot  removed  from  a.  TuETier's  tube,  on  the  fovirth  day.  Occlusion  has  resulted 
from  the  union  of  irregular  processes  of  clot,  which  have  united  at  the  centre,  and 
either  end,  enclosing  spaces.  The  green  strip  is  a  remnant  of  the  paraffin  lining 
of  the  tube,  still  adherent  to  the  clot. 


Gunshot  IiijiifU'S  to   the  Blood-rcssch,  p.  110 


GENERAL    LINES    OF    OPERATIVE    TREATMENT     111 

in  observing  care  that  the  coating  of  paraffin  be  not  disturbed  in  the 
process  of  introduction.  The  free  margins  of  the  apertures  are  the 
parts  most  Hkely  to  suffer.  Introduction  of  the  tube  into  the  proximal 
extremity  of  the  divided  vessel  is  easy,  but  that  into  the  distal  end 
often  gives  trouble  from  the  fact  that  it  is  already  contracted  and 
difficult  to  dilate  mechanically.  No  more  striking  exemplification  of 
the  force  exerted  by  the  normal  blood-pressure  can  be  afforded  than 
by  witnessing  the  difficulty  with  which  the  surgeon  can  stretch  the 
open  end  of  a  divided  vessel,  and  the  rapid  dilatation  which  at  once 
follows  entrance  of  the  blood-stream  when  the  junction  is  effected. 

The  following  formula  recommended  by  Captain  Bazett  for  a 
paraffin  mixture  to  coat  the  tubes  used  in  direct  transfusion  of  blood 
is  very  useful  for  coating  the  Tuffier  tubes,  and  their  introduction  is 
much  facilitated  by  the  employment  of  a  pair  of  forceps  made  upon 
the  same  pattern  as  one  of  Professor  Tuffier 's  :  About  equal  parts 
of  paraffin  wax  and  vaseline  are  mixed,  the  proportion  of  each 
being  slightly  modified  so  as  to  obtain  a  mass  which  will  set  at  from 
43°  to  48°  C.  The  mixture  is  then  strained  through  cotton-wool. 
The  tubes  are  coated  by  immersing  them  in  the  mixture  heated  to 
about  130°  C,  taking  care  to  avoid  the  presence  of  air-bubbles. 


113 


Wounds  of  Individual    Vessels. 


CHAPTER     VII. 
THE     GREAT     VESSELS     OF     THE     TRUNK. 

The  fatality  attendant  upon  wounds  of  the  great  vessels  of  the  ti'unk 
cannot  be  better  illustrated  than  by  reference  to  the  Table  (p.  7) 
which  shows  the  regional  distribution  of  the  cases  dealt  with  in 
this   essay. 

In  all  communications  concerning  gunshot  injiu'ies  to  the  chest 
and  the  abdomen,  haemorrhage  is  generally  acknowledged  to  be  the 
main  cause  of  early  death  ;  and  in  considering  the  effects  of  gunshot 
wounds  of  the  lungs,  haemorrhage  into  the  pleural  cavity  and  its  con- 
sequences obtain  a  dominant  position. 

VESSELS     OF     THE     CHEST. 

Aorta — That  a  Avound  of  the  thoracic  aorta  need  not  prove  imme- 
diately fatal  is  not  a  novel  observation.     Fig.  32  depicts  a  specimen  of 


Fig.  32. — Spherical  ball  ^TOuncl  of  the  ascending  aorta.      Plug  of  soft  tissues, 
and  bullet  retained  in  the  lumen  of  the  vessel. 

Mr.  Guthrie's  preserved  in  the  Museum  of  the  Royal  College  of  Surgeons 
(No.  3051).     In  this  instance  the  patient  died  on  the  third  day,  and 

'  8 


114      GUNSHOT    INJllUES    TO    THE    BLOOD-VESSELS 

temporary  lurmostasis  appears  to  ha\e  Ix'en  effeeted  by  a  plug  of  the 
skin  and  soft  tissues  carried  by  the  spherical  bullet  into  the  aperture 
in  the  wall  of  the  artery.  This  mode  of  spontaneous  closure  of  a 
defect  in  the  arterial  wall  is  not,  I  think,  common,  although  mention 
is  made  of  it  in  the  case  of  a  woimd  of  the  brachial  artery  recorded 
by  Sir  W.  Stokes  quoted  on  p.  27.     Wlicn  Guthrie's  specimen  was 


Fig.  33. — Bullet  wound  of  thoracic  aorta,  fifth  day.     Infiltration  of  mediastinal 
connective  tissue  with  blood,  but  no  aneurj-smal  sac.     Capt.  Adrian  Stokes. 


first  removed  from  the  body,  the  bullet  was  retained  in  its  position 
against  the  wall  of  the  artery  by  a  covering  of  fibrinous  clot  and  pos- 
siblj^  shreds  of  the  fibrous  tissue  it  had  carried  with  it  into  the  lumen 
of  the  aorta. 

A  beautiful  specimen  obtained  by  Captain  Adrian  Stokes,  from  a 
post-mortem  examination  performed  in  a  fatal  case  of  injury  to  the 


THE    GREAT    VESSELS    OF    TILE    TRUNK  115 

chest  in  which  a  large  hpcmothorax  was  the  prominent  featiire,  is  pre- 
served in  the  War  Collection  at  the  Koyal  College  of  Snrgeons  [Fig.  33). 
The  patient  sustained  a  perforating  wound  of  the  chest,  and  during 
the  next  twenty-four  hours  was  operated  upon,  and  four  pints  of  blood 
were  evacuated  from  the  right  pleural  cavity.  The  wound  underwent 
a  severe  streptococcal  infection,  and  as  a  result  the  patient  died  on 
the  fifth  day  after  reception  of  the  injury.  At  the  autopsy  the  areolar 
tissue  of  the  posterior  mediastinum  was  found  to  be  densely  infiltrated 
with  blood-clot,  but  no  aneurysmal  cavity  was  present.  A  slit  aper- 
ture of  entry  was  found  in  the  descending  aorta,  and  the  bullet  which 
had  caused  this  wound  was  discovered  in  the  right  common  iliac  artery 
with  the  base  directed  downwards.  There  is  no  reason  to  assume, 
from  the  conditions  discovered  after  death,  that  this  patient  might 
not  have  recovered  so  far  as  the  aortic  injury  was  concerned. 

The  instances  of  spontaneous  closure  of  the  abdominal  aorta 
referred  to  on  p.  26  and  p.  119  wovild  also  seem  to  support  the  view 
that  wounds  to  the  thoracic  aorta  inflicted  by  bullets  of  small  calibre 
or  minute  fragments  of  shell  may  in  like  manner  heal  spontaneously 
and  escape  observation.  This  possibility  helps  to  make  the  exact 
localization  of  arterio-venous  communications  situated  within  the 
confines  of  the  thorax  a  matter  of  some  difliculty  ;  the  following  case 
forms  an  illustrative  example. 

Case  1. — Thoracic  arterio-venous  communication,  transverse  arcii  of 
the  aorta  or  left  subclavian  artery. 

Pte.  W.  A  bullet  entered  at  the  centre  of  the  left  supraspinous  fossa, 
and  was  retained  beneath  the  centre  of  the  manubrium  sterni. 

Some  haemoptysis  followed  the  reception  of  the  wound,  and  a  left 
haemothorax  developed.  The  man  was  kept  at  rest  at  the  casualty  clearing 
station  for  a  week,  and  then  transferred  to  a  hospital  on  the  lines  of  com- 
munication. On  admission,  there  was  some  cellular  emphysema  at  the  root 
of  the  neck  on  the  left  side,  and  a  large  haemothorax  with  considerable  dis- 
placement of  the  heart  to  the  right,  but  the  man's  general  condition  was 
good.  Respiration  was  easy,  the  pulse-rate  90,  and  the  heart's  action  was 
not  excited.     The  left  radial  pulse  was  present  and  unaltered. 

A  loud  arterio-venous  bruit  was  audible  over  the  entire  praecordial 
area,  louder  still  over  the  manubrium  sterni,  and  attaining  its  greatest 
intensity  over  the  sternal  end  of  the  left  cla^dcle.  It  was  audible  in  both 
posterior  triangles  of  the  neck,  but  stronger  in  the  left.  I  was  inclined  to 
localize  the  communication  to  the  left  subclavian  artery. 

During  the  next  fourteen  days  the  patient  remained  in  much  the  same 
condition,  but  he  then  had  a  sudden  attack  of  dyspnoea  and  became  excited 
and  depressed  by  turns.  The  character  of  the  bruit  at  this  time  underwent 
considerable  alteration  ;  the  systolic  element  took  on  a  sharp  whistling 
character,  and  the  venous  roar  became  lower  in  pitch  and  softer  in  tone. 
The  normal  cardiac  sounds  could  be  very  readily  distinguished  from  the 
adventitious  vascular  murmur,  and  the  latter  had  become  more  strongly 
conducted  towards  the  right  side  of  the  chest.  I>ittle  change  had  taken 
place  in  the  condition  of  the  haemothorax. 


no      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

The  paticMit  wns  kept  at  rest  in  bed  duriiio'  the  sueceedino-  four  weeks, 
and  steadily  improved.  Tiie  whistlino-  character  of  the  systoHc  element  of 
the  bruit  was  maintained,  the  venous  roar  becomino-  still  less  prominent. 
The  raflial  pulses  were  equal  in  strength  and  volume.  The  ha^mothorax 
steadily  decreased  in  extent,  and  dyspncea  and  distress  disapjieared  com- 
pletely. An  .»'-ray  plate  revealed  a  shadow  in  the  ujjper  ])art  of  the  cliest, 
extendina  beyond  the  right  border  of  the  sternum,  but  neither  ])ulsation  nor 
tiirill  could  be  detected  in  the  upper  intercostal  spaces. 

At  the  end  of  seven  weeks  the  man  was  transferred  to  P'olkestone, 
where  he  stayed  three  months,  and  was  then  sent  back  to  Canada  to  be 
discharged  from  the  service. 

^^  hile  at  Folkestone  a  second  skiagram  was  taken,  and  the  skiagrapher 
was  of  opinion  that  the  lesion  was  one  of  the  transverse  portion  of  the  arch 
of  the  aorta.  The  man  was  complaining  of  occasional  attacks  of  breath- 
lessness   at  night,  but  was  otherwise  comfortable. 

Innominate  Vessels. — Aneurysmal  varices  of  the  innominate 
vessels  are  occasionally  met  with,  but  I  have  only  once  had  the  oppor- 
tunity of  observing  an  arterio- venous  aneurysm,  and  never  a  pure 
arterial  ha?matoma. 

Quotation  of  the  three  cases  which  have  come  under  my  own 
observation  will  probably  be  more  useful  than  any  attempt  to  give  a 
detailed  description  of  innominate  lesions.  The  first  case  is  of  special 
interest  as  illustrating  one  of  the  anomalous  types  of  ha^matoma  which 
may  be  met  with  in  aneurysms  due  to  gunshot  injiuy,  while  the  third, 
an  old  experience,  is  quoted  as  an  example  of  the  occiuTcnce  of  spon- 
taneous closure  of  an  arterio-venous  communication. 

Case  2. — ^Innomlnate  arterio-venous  aneurysm.  Death  from  secondary 
hsemorrhage  on  the  tenth  day. 

Pte.  A.,  age  19.  The  man  was  wounded  by  a  small  fragment  of  shell 
which  entered  over  the  centre  of  the  right  supraspinous  fossa,  and  was 
retained  in  the  chest.  He  was  kept  at  rest  at  the  casualty  clearing  station 
for  some  days,  and  then  transferred  to  a  hospital  on  the  lines  of  communi- 
cation. He  was  brought  to  my  notice  on  the  seventh  day  after  reception 
of  the  wound,  as  a  youth  suffering  with  congenital  heart  mischief,  the 
diagnosis  having  been  made  as  a  result  of  the  roaring  murmur  audible  in 
the  praicordium  and  at  the  back  of  the  chest.  The  boy  was  then  somewhat 
cyanosed  and  dyspna?ic,  but  not  in  great  distress.  He  had  expectorated  a 
good  deal  of  blood  for  the  first  two  days  after  the  injury,  but  none  since; 
the  temperature  was  normal,  the  pulse-rate  120. 

On  palpation,  some  pulsation  and  a  purring  thrill  were  detected  above 
the  right  clavicle.  The  right  apex  was  dull  on  percussion,  and  the  breath 
sounds  were  diminished  and  tubular  at  the  right  base. 

On  the  evening  of  the  same  day  the  patient  died,  as  a  result  of  a  ])ro- 
fuse  haemoptysis. 

At  the  auto})sy,  a  wound  the  size  of  the  little  finger-nail  was  found  on 
the  anterior  surface  of  the  root  of  the  innominate  artery  ;  the  wound  of 
the  vein  could  not  be  localized.  The  apical  area  of  the  pleui-al  sac  was 
obliterated  by  old  adiiesions  ;  hence  the  absence  of  a  hiemothorax.  The 
sac  was  formed  by  an  old  tuberculous  cavity  in  the  apex  of  the  right  lung, 
and  within  its  confines  a  small  sharp  fragment  of  shell  was  found. 


THE    GREAT    VESSELS    OF    THE    TRUNK  117 

Case  3. — Pte.  X.  was  admitted  with  a  small  slit  entry-wound  situated 
over  the  left  sternoclavicular  joint.  The  missile  was  retained  and  its  posi- 
tion was  never  discovered.  The  patient  was  suffering  from  an  extensive 
right  haemothorax  and  was  very  ill.  During  the  next  ten  days  he  improved, 
and  meanwhile  the  whole  chest  was  examined  almost  daily,  and  was  also 
aspirated. 

On  the  eleventh  day  a  double  machinery  murmur  was  heard  for  the  first 
time  by  Lt.-Col.  T.  R.  Elliott,  under  whose  observation  the  man  had  been 
since  his  admission.  The  systolic  element  was  of  the  'slamming'  or  'pistol- 
shot'  character,  the  roar  was  conducted  loudly  to  both  sides  of  the  neck 
and  to  the  base  of  the  heart.  A  bubbling  thrill  was  palpable  in  the  line  of 
the  right  axillary  vein.  A  week  later  there  was  little  change,  except  that 
the  thrill  was  now  felt  only  in  the  line  of  the  jugular  vein  in  the  neck,  and 
that  the  murmur  was  louder  and  more  definitely  localized  over  the  line  of 
the  innominate  vessels.  No  local  dullness  was  to  be  detected  beneath  the 
first  piece  of  the  sternum  or  in  the  vipper  right  intercostal  spaces.  The 
patient  was  shortly  afterwards  transferred  to  England. 

In  contrast  with  the  above  two  cases,  one  observed  during  the 
South  African  Campaign  may  be  shortly  narrated.*  I  had  the 
opportunity  of  keeping  in  touch  with  this  patient  for  some  years. 

Case  4. — The  wound  was  caused  by  a  Mauser  bullet,  which,  entering 
at  the  posterior  border  of  the  sternomastoid  on  the  left  side  of  the  neck, 
crossed  the  chest  to  emerge  at  a  point  in  the  right  anterior  axillary  line  one 
inch  below  the  fold. 

Some  haemoptysis  followed  the  injury  ;  and  later,  some  pulsation,  a 
thrill,  and  an  arterio-venous  bruit  were  detected  over  a  circular  prominent 
area  the  centre  of  which  corresponded  with  the  right  sternoclavicular 
joint.  I.ittle  change  occurred  in  the  signs,  except  that  some  gravitation 
ecchymosis  became  apparent  at  the  lower  costal  margin  on  the  right  side 
and  in  the  epigastrium. 

The  patient  suffered  little  inconvenience,  but  was  discharged  from  the 
service,  and  at  the  end  of  seven  months  returned  to  his  occupation  as  a  lamp 
trimmer. 

Four  and  a  half  years  later  the  arterio-venous  bruit  was  the  only  per- 
sisting sign  ;  at  the  end  of  five  and  a  half  j'^ears  the  bruit  had  disappeared, 
and,  except  for  a  somewhat  distended  external  jugular  vein,  no  evidence  of 
the  original  vascular  injury  remained. 

Other  Vessels. — I  have  seen  no  instance  in  which  the  intrathoracic 
portion  of  the  left  carotid  artery  was  suspected  as  the  seat  of  a  lesion, 
but  a  case  of  injury  to  the  left  subclavian  artery  within  the  thorax 
is  recorded  in  my  book  Surgical  Experiences  in  South  Africa,  and  one 
is  reported  here  on  p.  188.  The  following  case  is  quoted  as  illus- 
trating the  difficulty  in  correctly  localizing  an  intrathoracic  lesion. 

Case   5 . — Intrathoracic  arterio-venous  communication  of  uncertain  position. 

Pte.  li.     A  small  aperture  of  entry  was  present  at  the  left  margin  of 

the  manubrium  sterni  in  the  first  intercostal  space,  and  a  sldagram  showed 

*  Surgical  Experiences  in  South  Africa,  p.  140. 


118      GUXSJIOT    INJURIES    TO    TIIK    BLOOD-VESSELS 

a  small  fraii'ment  of  shell  api)aiently  lyino-  one  inch  anterior  to  the  root  of 
the  transverse  process  of  the  fourth  dorsal  \ertebra  of  the  right  side.  The 
signs  ])resent  shortly  after  the  injury  suggested  a  small  ha^niothorax. 

At  the  end  of  a  month,  when  the  case  came  under  my  observation,  the 
patient  was  in  no  distress,  the  pulse-rate  varied  from  70  to  100,  the  radial 
pulse  was  jiresent  and  equal  on  the  two  sides,  and  there  was  paralysis  of 
the  sympathetic  of  the  left  side. 

A  loud  arterio-x'cnous  bruit  was  audible  over  the  front  of  the  chest, 
loudest  at  the  situation  of  the  wound  of  entry  ;  this  was  conveyed  to  the 
left  jDosterior  triangle,  but  not  to  the  left  arm.  The  apex  of  the  heart  was 
just  within  the  nipple  line,  cardiac  pulsation  was  heaving  and  visible,  the 
sounds  were  clear.  A  cardiographic  examination  made  by  Dr.  Cassidy 
revealed  no  abnormality. 

The  patient  was  kept  at  rest  in  bed  for  two  months,  during  which  time 
he  did  not  complain  of  any  discomfort  ;  he  was  then  allowed  to  get  up  and 
about,  and  at  the  end  of  four  months  was  discharged  from  the  service, 
suffering  no  inconvenience  when  taking  life  easily. 

Wounds  of  the  parietal  vessels  of  the  chest  have  proved  to  be  a 
much  less  frequent  source  of  the  blood  in  cases  of  ha;niothorax  than 
was  believed  to  be  the  case  before  the  present  war,  and  Elliott 
and  Henry*  have  proved  conclusively  by  post-mortem  observations 
that  the  pulmonary  vessels  form  the  most  common  source  of  supply. 
In  the  section  dealing  with  the  svibclavian  vessels  generally,  some 
cases  will  be  found  bearing  on  this  question  beyond  that  just  recited 
above. 

Mediastinal  ha?morrhage  does  not  occupy  such  a  prominent 
position  in  relation  to  injuries  of  the  thoracic  vessels  as  does  retro- 
peritoneal to  those  of  the  abdomen,  because  the  extravasated  blood  is 
not  so  liable  to  secondary  infection  from  the  viscera  ;  but  gravitation 
ecchymosis  at  the  low^er  margin  of  the  thorax  sometimes  affords  a 
useful  diagnostic  indication. 

I  have  met  with  one  case  of  arterial  aneurysm  in  connection  with 
a  wound  of  a  branch  of  the  internal  mammary  artery.  The  chief 
interest  in  this  observation  depended  on  the  fact  that  although  the 
local  systolic  bruit  was  loud  and  in  near  proximity  to  the  heart,  yet 
it  was  not  conducted,  as  maj'  be  the  case  in  more  distant  arterial 
lesions. 

VESSELS     OF     THE     ABDOMEN. 

Wounds  of  the  visceral  arteries  accomit  for  a  very  large  proportion 
of  the  deaths  which  follow  gmishot  w^ounds  of  the  abdomen,  and  in 
many  instances  wounds  of  the  visceral  arteries  are  dealt  -with  during 
the  performance  of  abdominal  explorations.  Injuries  of  the  latter 
character  are  commonly  complicated  by  coexistent  ones  of  the  viscera. 


*  Journal  of  the  Royal  Army  Medical  Corps,  vol.  xxvii,  Nov.  1916,  p.   552. 


THE    GREAT    VESSELS    OF    THE    TRUNK  110 

and  need  no  further  mention  here.  It  may  be  remarked,  however, 
that  it  is  not  common  to  meet  with  cases  of  secondary  haemorrhage 
from  the  intestinal  vessels  in  the  hospitals  on  the  lines  of  communi- 
cation or  at  the  base  ;  while,  on  the  other  hand,  deaths  following 
womids  of  the  solid  abdominal  viscera  are  attributable  to  secondary 
hremorrhage  in  from  forty  to  fifty  per  cent  of  all  fatal  cases.* 
These  deaths  are  mostly  consequent  on  secondary  infection,  and 
as  a  rule  the  bleeding  is  not  from  vessels  of  the  first  magnitude, 
the  latter  having  already  exacted  their  toll  in  the  primary  stages  of 
the  injuries. 

In  arterial  surgery  the  interest  rather  centres  upon  retroperitoneal 
injuries,  and  on  wounds  of  the  parietal  series  of  vessels.  There  can 
be  little  doubt  in  the  great  majority  of  instances  in  which  a  missile 
crosses  the  peritoneal  cavity  and  implicates  the  aorta  or  the  iliac 
vessels,  or  even  the  great  veins,  that  the  patients  die  rapidly  from 
intraperitoneal  hjcmorrhage.  Again,  when  the  haemorrhage  is  retro- 
peritoneal, although  death  may  be  deferred,  not  a  few  of  the  patients 
succumb  as  a  result  of  secondary  infection  of  the  masses  of  clot  which 
infiltrate  the  extraperitoneal  tissue.  This  opinion  is  supported  by 
the  fact  that,  in  the  series  of  cases  upon  which  this  essaj^  is  founded, 
only  one  injury  to  the  abdominal  aorta  and  five  to  the  iliac  vessels 
are  met  with. 

Abdominal  Aorta. — In  the  general  section  (p.  26),  reference  has 
been  made  to  a  classical  case  of  spontaneous  closure  of  a  bullet  wound 
of  the  abdominal  aorta,  and  by  the  kindness  of  Captains  Morgan  and 
Young  I  am  able  to  quote  a  case  observed  during  the  present  w'ar,  in 
which  the  patient  survived  a  bilateral  perforation  of  the  aorta  by  a 
fragment  of  shell  for  more  than  three  weeks,  and  eventually  died  from 
other  causes.  The  preparation  from  w^hich  Fig.  34  has  been  drawn  is 
preserved  in  the  AVar  Collection  at  the  Roj^al  College  of  Surgeons 
(No.  664)„ 

Case  6. — Cpl.  R.,  age  32,  was  admitted  into  Millicent  Duchess  of  Suther- 
land's Hospital  five  days  after  receiving  two  wounds,  one  in  the  left  axilla, 
the  second  just  within  the  vertebral  border  of  the  left  scapula.  The  wounds 
were  almost  healed  at  the  time  of  admission,  and  were  at  first  thought  not 
to  have  penetrated  the  thorax.  The  injury  had  been  followed  by  moderate 
haemoptysis  and  some  dyspnoea,  but  by  no  abdominal  pain. 

When  admitted  to  hospital  on  the  fifth  day,  the  patient  was  slightly 
dyspnoeic,  but  there  were  no  abdominal  signs  ;  the  temperature  was  101-6°  F., 
and  the  pulse-rate  116.  The  signs  discovered  in  the  chest  were  sMght,  and 
considered  to  indicate  either  a  small  hfemothorax  or  a  traumatic  pneumonia. 
An  ,x'-ray  examination  showed  slight  opacity  at  the  left  base,  and  the  out- 
line of  the  diaphragm  was  obscured.     An  exploring  needle  entered  at  the 

*  British   Journal  of  Surgery,    1916,  vol.  iii,  No.    12,  p.   650. 


120      GUNSHOT    INJUIilES    TO    THE    BLOOD-VESSELS 

left  base  gave  a  nc<>ative  result.  Tlie  al^donien  was  supple  and  not  tender  : 
there  was  sliolit  jaundice  of  the  conjunctiva'. 

During'  th-c  next  few  days  the  patient's  general  condition  improved, 
the  evening  temperature  rose  to  101°  to  102',  but  the  pulse-rate  averaged 
only  88. 

On  the  seventeenth  day  after  the  injiu-y  the  man  began  to  vomit  freely, 
and  complained  of  pain  all  over  the  abdomen  ;  the  latter  remained  supple, 
but  was  tender  throughout,  and  distended.  A  rectal  examination  aflorded 
no  information.  The  signs  in  the  chest  had  cleared  up,  except  for  evidence 
of  slight  bronchitis  in  both  lungs. 

All  food  by  mouth  was  forbidden,  pituitrin  was  administered  sub- 
cutaneously,  and  dextrose  was  given  by  enema.  These  measures  relieved 
the  vomiting  and  distention,  but  the  abdominal  pain  persisted,  and  on  the 
twentieth  day  became  localized  to  the  right  half  of  the  abdomen.  Some 
resistance  to  palpation  now  developed,  especially  in  the  right  iliac  fossa. 
A  repeated  rectal  examination  proved  negative.  The  temperature  was 
101°,  and  the  pulse-rate  had  risen  to  100. 

A  diagnosis  of  appendicitis  was  made,  and  a  laparotomy  performed. 
The  operation  disclosed  little  beyond  the  existence  of  generalized  distention, 
and  some  old  adhesions  in  the  region  of  the  appendix  ;  there  was  no  excess 
of  peritoneal  fluid. 

The  pain  and  vomiting  continued,  the  temperature  remained  high,  the 
pulse  became  progressively  more  rapid  and  weaker,  and  on  the  twenty- 
third  day  the  patient  died  :  there  was  never  any  liEematuria,  and  the  colora- 
tion of  the  conjunctivae  had  not  appreciably  increased. 

Autopsy,  by  Captain  R.  J.  Bethune. — On  incising  the  scar  an  inch 
below  the  left  axillary  folds  and  just  posterior  to  the  mid-axillary  line,  a 
track  leading  to  the  left  pleural  cavity  could  be  distinguished.  No  track 
could  be  detected  leading  from  the  scar  at  the  vertebral  border  of  the 
scapula.  Half  a  pint  of  bloody  fluid  was  found  in  the  left  pleural  cavity,  and 
tenacious  adhesions  were  present  in  both  pleurae  between  the  lung  and  chest 
wall.  The  upper  and  the  inner  surfaces  of  the  sixth  rib  Avere  gTooved 
and  denuded  of  periosteum. 

An  aperture  half  an  inch  in  diameter  was  found  in  the  diaphragm  near 
the  mid-line  and  towards  the  back  of  that  portion  of  the  muscle  in  contact 
with  the  inferior  surface  of  the  lower  lobe  of  the  left  lung.  The  opening 
was  partially  closed  by  a  tag  of  omentum,  which  adhered  to  its  margin. 
(The  specimen  can  be  seen  at  the  Roj^al  College  of  Surgeons,  No.  665). 

The  myocardium  was  paler  than  normal,  and  broke  down  with 
moderate  digital  pressure.  The  pei'icardium,  endocardium,  and  valves  were 
normal. 

A  moderate  quantity  of  clear  brownish  fluid  was  foimd  in  the  peri- 
toneal cavity,  no  blood  or  pus,  and  no  evidence  indicative  of  recent  peri- 
tonitis. The  spleen  was  enlarged,  soft,  and  of  an  opaque  pink  colour. 
The  liver  was  enlarged,  soft,  and  yellow  in  colour.  On  section,  a  fatty  area 
was  seen  at  the  upper  aspect  of  the  left  lobe,  corresponding  in  position 
with  the  overlying  aperture  in  the  diaphragm.  The  connective  tissue  of 
the  capsule  was  infiltrated  with  blood.  The  fundus  of  the  gall-bladder  was 
adherent  to  the  transverse  colon,  the  organ  was  not  distended,  and  its 
contents  were  normal  in  character.  The  kidneys  were  somewhat  swollen, 
soft,  and  pale.  They  presented  no  sign  of  injury.  The  pancreas  was 
embedded  in  blood-clot,  but  no  sign  of  interstitial  haemorrhage  was  seen 
on  section. 


THE    GREAT    VESSELS    OF    THE    TRUNK 


121 


The  entire  retroperitoneal  tissue  was  infiltrated  with  soft  hlood-elot, 
the  mass  being  greatest  in  the  right  renal  region,  and  around  tiie  right  crus 
of  the   diaphragm  and  tlie   pancreas.      When   the   right   kidney   had   been 


\ 


Fig.  34. — Bilateral   perforation   of  abdominal  aorta  by   shell   fragmsnt. 

removed  by  division  of  the  vessels  entering  the  hilus,  a  small,  more  or  less 
cylindrical  fragment  of  metal^  measuring  one-half  by  one-quarter  of  an  inch, 
was  found  in  the  clot  near  the  pedicle.     Two  apertures  were  found  in  the 


122      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

aorta  just  above  the  level  of  origin  of  the  renal  arteries.  One  oj)eiiing  was 
triaii<>uUu'  in  shape,  with  a  small  flap,  the  other  was  oval  with  ragoed 
niargiiTs.  The,  openings  jjerniitted  the  passage  of  the  fragment  of  metal 
introdueed  lengthwise  (Fig  34). 

The  lumen  of  the  vena  cava  could  not  be  clearly  distinguished  on 
account  of  the  hrm  clot. 

Captain  13^'tliime  makes  the  following  remarks  :  "•  The  post-mortem 
e\idene*'  ])oints  to  septicaemia  as  the  cause  of  death.  It  is  remarkable  that 
neither  blood  nor  blood-clot  was  seen  in  the  peritoneal  cavity  either  at  the 
ojicrat ion. performed  on  the  seventeenth  day  or  at  the  post-mortem  exam- 
ination made  upon  the  twenty- fourth.  Had  there  been  a  hole  in  the 
posterior  peritoneal  layer,  death  would  surely  have  occurred  rapidly  froni 
haemorrhage  into  the  peritoneal  cavity.  The  conditions  found  on  both 
occasions  suggest  that  the  projectile  passed  through  the  lesser  sac  of  the 
peritoneum,  subsequently  travelling  in  the  subperitoneal  tissue  of  the  aorta. 
If  one  may  assume  that  the  man  was  lying  on  his  face  when  he  received  the 
wound  in  the  axilla,  the  escape  of  the  stomach  and  liver  from  injury  may 
be  accounted  for  by  the  falling  forward  of  these  viscera  towards  the  anterior 
abdominal  wall.  One  other  point  is  deserving  of  notice,  namely,  that  no 
suppuration  or  abscess  was  found  in  the  clot  or  elsewhere  which  might 
have  acted  as  a  focus  for  the  septicaemia." 

Iliac  Vessels. — Only  five  cases  of  injury  to  the  iliac  vessels  are 
included  in  the  series,  yet  these  afford  several  points  of  interest,  and 
they  are  therefore  all  quoted  briefly  below\  Injuries  to  these  vessels 
may  be  readily  overlooked,  as  they  are  commonly  complicated  by 
visceral  lesions  ;  while,  if  retroperitoneal,  the  primary  blood  extra- 
vasation tends  to  be  ill-marginated,  widespread,  and  obscured  by  the 
presence  of  abdominal  distention.  For  these  reasons  auscultation 
may  be  the  chief  or  the  sole  aid  at  the  disposal  of  the  surgeon  in 
making  a  diagnosis. 

It  is  noteworthy  that  of  the  five  cases  here  dealt  with,  the  injury 
was  to  the  loAver  part  of  the  external  iliac  artery  in  three,  and  I  think 
it  may  be  assumed  that  the  lower  the  wound  is  situated  in  the  course 
of  this  vessel,  the  greater  is  the  chance  of  the  haemorrhage  being 
restrained.  A  difficulty  may  arise,  when  the  wounds  are  in  this 
position,  in  discriminating  between  a  wound  of  the  external  or  the 
common  femoral  artery,  because  the  blood  extravasation  may  some- 
times track  downwards  into  the  thigh,  or  in  some  cases  track  upwards 
from  the  thigh  into  the  iliac  fossa.  Observation  of  the  possible  coiu'se 
taken  by  the  bullet,  and  careful  auscultation,  may  be  the  only  means 
of  correctly  localizing  the  jDoint  of  injury.  I  have  seen  mistakes 
made  in  this  particular,  and  they  are  the  more  intelligible  since  the 
iliac  swelling  is  sometimes  the  more  prominent  featin-e  in  femoral 
lesions.  In  an  interesting  operation  in  which  I  assisted  Colonel  J. 
Gunn,  C.A.M.C,  an  arterio-venous  aneurysm  ostensibly  of  the  left 
external  iliac  artery  and  vein  proved  to  be  due  to  a  woimd  of  the 
deep  circumflex  iliac  vessels,  in  close  proximity  to  the  parent  trunk. 


THE    GREAT    VESSELS    OF    TILE    TRUNK  ^23 

Again,  the  fact  that  the  blood  in  the  retroperitoneal  injuries 
rapidly  clots  in  the  meshes  of  the  loose  connective  tissue,  may  account 
for  absence  of  expansile  pulsation  in  the  early  stages  of  the  cases. 

Case  7. — ^ Abdominal  wound.  Wounds  of  the  intestine.  Arterial  haema- 
toma  of  the  external  iliac  vessels.     ?  Spontaneous  cure. 

Pte.  E.  A  piece  of  shell  entered  the  abdomen  at  the  outer  margin  of 
the  left  rectus  muscle,  one  inch  above  Poupart's  ligament. 

The  abdomen  was  explored  by  Captain  Meyer  twenty-four  hours  later, 
and  five  perforations  of  the  small  intestine  situated  at  the  lower  end  of  the 
jejunum  and  the  commencement  of  the  ileum  were  found.  Two  of  the 
perforations  were  sutured,  and  the  piece  of  intestine  containing  the  remain- 
ing perforations  was  excised  en  masse. 

Blood-clot  was  removed  from  Douglas's  pouch  and  from  the  aiiterior 
abdominal  wall,  and  it  was  noted  at  the  time  that  the  femoral  vessels  were 
pulsating  normally. 

The  after-progress  was  uneventful,  and  at  the  end  of  fourteen  days 
the  patient  was  transferred  to  a  hospital  on  the  lines  of  communication.  His 
general  condition  was  good,  but  two  days  later  he  complained  of  pain  in 
the  left  groin,  and  on  examination  a  small  diffuse  swelling  was  discovered 
beneath  Poupart's  ligament.  Pulsation  and  a  blowing  systolic  murmur  were 
present,  but  no  thrill.  The  condition  of  the  limb  was  normal,  and  a  good 
posterior  tibial  pulse  was  present. 

The  patient  was  kept  at  rest,  and  three  weeks  later  the  swelling  had 
practically  disappeared,  the  pulsation  was  localized  to  the  line  of  the 
artery,  and  the  systolic  murmur  had  become  very  faint.  A  few  days  later 
the  man  was  transferred  to  England,  and  no  further  details  are  to  hand. 

Case  8. — Arterio- venous  aneurysm  of  the  external  iliac  artery. 

L.-Cpl.  M.  The  man  was  wounded  by  a  revolver  bullet,  which  entered 
above  the  centre  of  Poupart's  ligament  on  the  left  side  and  was  retained, 
lying  about  at  the  same  level  on  the  posterior  abdominal  wall.  The  tibial 
pulses  were  maintained,  and  good.  There  was  a  well-marked  thrill  over 
the  situation  of  the  wound,  and  a  loud  machinery  murmur  extending  down 
to  the  foot  and  upwards  as  far  as  the  lower  margin  of  the  thoracic  wall. 
The  venous  roar  alone  was  audible  in  the  cardiac  area.  The  patient  was 
transferred  to  England  for  treatment. 

Case  9. — Wound  of  external  iliac  artery.  Primary  ligature  of  artery 
and  vein. 

Lieut.  B.  Both  artery  and  vein  were  lacerated  by  a  fragment  of  shell. 
and  were  ligatured.  Twelve  days  later  the  primary  wound  had  healed,  and 
the  lower  limb  was  in  good  condition. 

Case  10. — Complete  severance  of  common  iliac  ai'tery.  Haemothorax. 
Death  on  thirteenth  day. 

Pte.  E.  The  patient  was  wounded  by  a  fragment  of  a  trench  mortar 
shell,  which  entered  to  the  left  side  of  the  lower  dorsal  vertebrae.  A 
haemothorax  developed  promptly,  and  eight  to  ten  hours  after  reception 
of  the  wound  the  man  began  to  complain  of  pain  in  the  left  lower  limb, 
which  became  swollen. 

After  a  stay  of  nine  days  at  the  casualty  clearing  station,  the  patient 
was   transferred   to    a    hospital    on    the    lines    of    communication.     When 


124      GUNSHOT    INJUIUES    TO    THE    BLOOD-VESSELS 

admitted  he  looked  pale  and  ill  ;  he  was  restless,  with  a  good  deal  of  cough, 
and  a  small  amount  of  blood-stained  mucus  was  still  being  expectorated. 
A  haMnothorax  extending  up  to  the  angle  of  the  scapula  was  present,  and 
on  examination  of  the  abdomen,  resistance  to  pressure  was  detected  in  the 
left  flank  and  iliac  fossa. 

The  right  lower  limb  was  thin  and  wasted  ;  the  left  swollen,  but  with 
no  subcutaneous  oedema,  and  the  calf  muscles  were  firm  and  resistant  on 
l^alpation.  Sensation  was  present  throughout  the  limb,  and  there  was  no 
loss  of  motor  power. 


Fig.  35. — Arterial  hajmatoma  developing  in  connection  ^^■ith  a  complete 
severaiice  of  the  common  iliac  artery.  The  cavity  laid  open,  and  a  portion  of 
the  clot  still  in  position. 


The  man  was  very  restless,  and  complained  much  of  pain  in  the  lower 
limb.  On  the  thirteenth  day  the  limb  became  still  more  tense,  and  pulsa- 
tion in  the  femoral  vessels  was  ablated.  Sensation  became  impaii'ed  in  the 
thigh,  and  although  the  limb  remained  warm,  the  foot  commenced  to  be 
discoloured  and  mottled.  On  the  fifteenth  day  the  man  died  suddenly 
from  no  obvious  cause. 

At  the  autopsy,  a  pint  and  a  half  of  blood  was  found  in  the  left 
pleural  cavity,  and  the  track  of  the  missile  was  traced  through  the  base 
of  the  left  lung,  diaphragm,  and  psoas  muscle.     After  emerging  from  the 


THE    GREAT    VESSELS    OF    THE    TRUNK  125 

latter,  the  missile  had  completely  severed  the  common  iliac  vessels  near 
their  commencement  {Fig.  85),  and  then  dropj^cd  into  J)oii<^Ias's  pouch. 
The  femoral  vein  was  thrombosed  as  low  down  as  the  popliteal  space.  A 
pint  of  bloody  fluid  was  present  in  the  peritoneal  cavity,  there  was  exten- 
sive retroperitoneal  extravasation,  and  a  larf>e  thick-walled  arterial  haima- 
toma  in  connection  with  the  severed  ends  of  the  artery. 

Case  11. — Wound  of  right  internal  iliac  artery.     Arterial  haematoma. 

L.-Cpl. — .  An  abdominal  exploration  resulted  in  the  discovery  of  a 
large  quantity  of  evil-smelling  clot  in  the  peritoneal  cavity,  but  no  visceral 
injury  was  detected,  neither  was  the  source  of  the  haemorrhage  localized. 

Three  days  later  a  secondary  haemorrhage  occurred,  but  again  the 
source  of  the  bleeding  was  not  localized.  The  man,  however,  improved  in 
condition,  and  ten  days  later  he  was  sent  down  the  lines.  At  this  time  he 
was  still  very  anaemic,  and  on  examination  a  systolic  apical  murmur  was 
detected.  There  was  a  marked  diastolic  shock  both  in  the  cardiac  sounds 
and  in  the  arteries,  and  diffuse  praecordial  pulsation. 

Continuous  improvement  took  place  in  the  general  condition,  and  on 
the  thirteenth  day  the  systolic  bruit  was  no  longer  audible  over  the  heart, 
but  a  blowing  systolic  murmur  was  localized  over  the  right  iliac  fossa,  which 
could  be  traced  upwards  to  the  aorta.  The  patient  was  shortly  afterwards 
transferred  to  England. 

Prognosis  and  TreatJuent. — The  above  material  affords  little  scope 
for  dogmatism  regarding  the  treatment  of  injuries  to  the  iliac  vessels  ; 
its  scantiness,  however,  supports  the  view  of  the  serious  results  which 
attend  wounds  in  this  region,  and  also,  I  think,  the  opinion  that 
wounds  of  the  distal  quarter  of  the  external  iliac  artery  are  the 
most  likely  to  be  met  with  by  the  surgeon.  The  cases  also  illustrate 
the  possibility  of  spontaneous  healing  in  this  region,  the  fact  that 
these  lesions  may  be  readily  overlooked  primarily,  and  that  the 
development  of  a  pulsating  hsematoma  may  be  deferred.  Case  10  is 
an  interesting  example  of  a  temporary  maintenance  of  the  circulation 
in  spite  of  practically  complete  severance  of  continuity  of  the  vessel. 

With  regard  to  the  treatment  of  aneurysms  of  the  iliac  arteries, 
it  is  clear  that  the  operation  may  need  to  be  of  the  transperitoneal 
type,  since  this  method  gives  the  surgeon  the  opportunity  of  establishing 
control  of  the  circulation  by  placing  a  i^rovisional  ligature  around  the 
common  iliac  or  the  commencement  of  either  of  its  branches,  as  may 
be  dictated  by  the  position  of  the  actual  lesion.  It  may  be  added 
that  placing  the  patient  in  the  so-called  Trendelenburg  position  much 
facilitates  any  procedure  undertaken  ;  otherwise  the  ordinarj^  rules 
guiding  the  treatment  of  arterial  or  arterio-venous  lesions  need  no 
modification. 

The  few  cases  recorded  furnish  no  reason  to  depart  from  the 
opinion  that  ligature  of  the  iliac  vessels  is  a  successful  procedure,  and 
that  unsatisfactory  ulterior  consequences  are  not  to  be  apprehended. 

This  is  perhaps  the  most  convenient  place  to  add  a  few  words  as 


126      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

to  the  results  of  lioatiirc  of  the  iHae  arteries  for  the  treatment  of  either 
common  fenioral  injuries  or  wounds  of  the  vessels  of  the  biittock. 
When  a  common  femoral  aneurysmal  sac  extends  up  to  or  above 
Poupart's  ligament,  the  transperitoneal  route  may  be  the  more  con- 
venient, as  it  allows  the  conformation  and  extent  of  the  sac  to  be  made 
out,  without  any  dissection.  I  have  seen  this  operation  done  twice 
with  good  results,  and  with  small  disturbance  of  the  idtimate  nutrition 
of  the  limb. 

AVhen  it  is  required  merely  to  expose  the  vessel  for  the  application 
of  a  provisional  ligature,  or  to  deal  with  a  small  aneurysm  of  the  lower 
part  of  the  vessel,  the  operation  shoidd  be  of  the  extraperitoneal  type, 
and  the  most  satisfactory  incision,  as  far  as  the  future  strength  of 
the  abdominal  wall  is  concerned,  is  that  in  which  the  rectus  sheath 
is  opened  and  the  rectus  itself  displaced,  as  in  operations  for  appcn- 
dicectomy  or  for  ex]3loration  of  the  pelvic  portion  of  the  ureter. 

Ligatiu'e  of  the  internal  iliac,  or  its  posterior  division,  has  been 
most  frequently  needed  for  the  treatment  of  hemorrhage  from  the 
vessels  of  the  buttock  or  for  the  treatment  of  gluteal  aneurysms.  In 
my  own  experience  this  is  the  only  form  of  proximal  ligature  at  a 
distance  for  secondary  haemorrhage  wdiich  has  afforded  good  results, 
and  which  is  to  be  regarded  as  a  normal  procedure.  I  have  seen  it 
employed  with  success  in  at  least  ten  instances.  Sloughing  of  the 
tissues  of  the  buttock  has,  however,  been  known  to  follow  it  when  the 
buttock  woitnd  was  infected  ;  and  it  is  scarcely  necessary  to  add  that, 
if  there  is  any  reason  to  suspect  anaerobic  infection  of  the  tissues, 
the  wound  in  the  buttock  must  be  maintained  very  widely  open. 

WOUNDS     OF     THE     GREAT  ]  VEINS. 

A  mmiber  of  specimens  illustrative  of  wounds  of  the  great  veins 
are  contained  in  the  War  Collection  at  the  Royal  College  of  Siu'geons. 
These  W'cre  obtained  mostly  from  the  bodies  of  patients  who  had 
other  visceral  injuries,  but  it  is  noteworthy  that  in  the  majority  of 
instances  death  occurred  during  the  first  twenty-foiu-  hours.  On 
p.  22  a  short  account  of  a  wound  of  the  portal  vein,  successfully  treated, 
is  recorded. 


127 


CHAPTER    VIII. 
VESSELS     OF     THE     NECK. 

CAROTID      ARTERIES. 

Tup:  injuries  to  the  earotid  arteries  that  come  into  the  hands  of  the 
surgeon  are  usually  of  a  hmited  character,  being  either  of  the  nature 
of  contusions,  lateral  wounds,  or  traversing  perforations.  In  only 
one  of  the  whole  series  of  cases  on  which  this  chapter  is  founded  was 
a  complete  severance  of  the  vessel  met  with.  Amongst  85  injuries 
treated  upon  the  lines  of  communication  or  at  the  base,  no  complete 
severance  was  diagnosed,  and  in  all  the  cases  operated  upon  the  lesion 
was  of  a  limited  nature.  It  may  also  be  noted  that  the  accompanying- 
wounds  of  the  soft  parts  were  of  a  similar  type  ;  thus,  amongst  66 
cases,  in  20  the  woimd  was  a  simple  through-and-through  track  of 
small  or  minimal  calibre,  in  45  the  missile  was  retained,  and  in  only 
1  was  the  external  wound  extensive. 

Among  60  injuries,  22  were  produced  by  bullets,  and  38  by 
fragments  of  shells  or  bombs,  often  of  very  small  size. 

As  to  the  position  of  the  injuries  in  the  course  of  the  vessels  : 
Of  85  cases,  44  were  on  the  right  side,  39  on  the  left  ;  in  2  cases 
the  vessels  of  both  sides  were  implicated.  Amongst  76  cases,  the 
external  carotid  was  wounded  in  9,  the  internal  in  9,  and  the  com- 
mon trunk  in  58.  The  49  injuries  to  the  common  carotid  were 
located  as  follows  :    upper  third  25,  middle  third  19,  lower  third  5. 

It  may  be  inferred  from  these  facts  that  if  the  wound  of  the  soft 
parts  of  the  neck  be  extensive,  or  if  the  vessel  be  completely  severed, 
a  fatal  result  usually  ensues.  The  small  proportion  of  injuries  to  the 
lower  third  of  the  vessel  suggests  that  woimds  in  this  part  of  its  course 
are  particularly  dangerous.  Lastly,  the  large  proportion  of  the  cases 
in  which  the  missile  was  retained,  and  was  a  fragment  of  a  shell,  illus- 
trates well  the  favourable  prognostic  significance  of  low  velocity  on 
the  part  of  the  missile  in  decreasing  the  severity  of  the  injury. 

Amongst  a  total  of  85  injiu'ies,  in  19  the  lesion  was  of  the  nature 
of  a  contusion,  or  of  a  wound  of  such  limited  extent  as  to  occasion 
no  gross  leakage  of  blood.  The  interest  of  this  small  series  of  cases  is 
twofold.  It  throws  light  on  the  possibility  of  spontaneous  closure  of 
wounds  of  great  vessels,  and  it  is  remarkable  that,  in  all,  the  lesion  was 
discovered,  not  by  the  presence  of  local  signs,  but  as  a  result  of  the 


128      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

remote  consccjuciiccs  it  was  rcspon,sil)lc  for.  The  seeond  feature 
seems  to  indieatc  also  that  thrombosis  Icadino'  to  spontaneous  healing 
of  arterial  lesions  eannot  be  uncommon,  since  the  occmTcnce  of  cerebral 
signs  was  alone  responsible  for  the  detection  of  the  vascidar  injury 
in  these  instances.  It  cannot  be  assumed  that  obliteration  of  the 
lumen  of  the  carotid  artery  as  a  sequence  of  contusion  is  more  likely 
to  be  followed  by  com]:)lications  in  its  area  of  distribution  than  may 
be  the  case  with  any  of  the  other  large  arteries  of  the  bod}''  ;  and,  in 
addition,  we  have  positive  eA'idence  that  extensive  obliterating  throm- 
bosis of  the  carotid  itself  may  be  evidenced  by  no  remote  consequences 
whatever.  Hence  we  are  justified  in  concluding  that  many  cases  of 
contusion  or  minimal  woimd  of  the  carotid  vessels  may  pass  unnoticed 
and  never  be  discovered. 

DIAGNOSIS    OF    INJURIES     TO     THE     CAROTID     ARTERIES. 

Observance  of  the  rules  guiding  the  investigation  of  a  suspected 
arterial  injury  in  any  region  suffices  to  determine  the  question  with 
comparative  ease  in  the  neck.  The  chief  difficulty  consists  in  the 
small  amomit  of  aid  which  can  be  obtained  in  this  region  by  investi- 
gation of  the  peripheral  pulse.  It  is  true  that  in  many  cases  of 
obstruction  of  the  main  trunk  seen  at  an  early  date,  the  pulsation  in 
the  external  carotid  may  be  absent  or  feeble,  but  after  a  very  short 
period  the  free  cross-anastomosis  between  the  arteries  of  the  two- 
sides  may  abolish  the  difference.  Although,  therefore,  we  may  obtain 
evidence  by  palpating  the  temporal  pulse,  it  cannot  be  regarded  as 
giving  an  absolute  indication  ;  and,  as  will  be  pointed  out  later, 
examination  of  the  fundus  oculi  is  useless  in  furnishing  an  estimate 
of  the  freedom  of  circulation  through  the  internal  carotid. 

Determination  of  the  important  question  as  to  whether  an  injury 
involves  the  carotid  immediately  above  or  immediately  below  the 
bifiu'cation  of  the  common  trimk,  can  usually  only  be  made  by  opera- 
tive exploration.  It  may  be  noted,  in  this  particular,  that  when  the 
internal  carotid  is  the  vessel  injured,  the  hasmatoma  is  generally  pal- 
pable beneath  the  tonsil,  and  tends  to  spread  backwards  ;  while  the 
extravasation  from  woimds  of  the  trimk  tends  rather  to  follow  the 
more  sujJcrficial  course  of  the  external  carotid.  The  existence  of  an 
intracranial  injury  to  the  internal  carotid  may  usually  be  determined 
by  auscultation  of  the  skull,  when  the  characteristic  systolic  bruit,  or 
an  arterio-venous  mm-mur,  will  be  audible.  Fig.  36  furnishes  an 
interesting  example  of  the  value  of  auscultation  imder  such  circum- 
stances. In  this  instance  a  fragment  of  shrapnel  case  had  entered  the 
skull,  and  the  injury  was  followed  by  the  development  of  a  pulsating 
exophthalmos,  which  was  at  first  thought  to  indicate  an  injury  tO) 


VESSELS    OF    THE    NECK 


120 


the  internal  carotid  artery  or  its  ophthalmic  branch.  The  absence  of 
any  vascular  murmur,  however,  negatived  this  view,  and  on  the  man's 
death  a  few  days  later,  the  pulsation  was  found  to  have  depended 
upon  the  jjrotrusion  of  a  hernia  cerebri  into  the  deep  part  of  the  orbit. 


Fig.  36. — Pulsating  exophthalmos,  due  to  a  hernia  cerebri  at  the  apex  of  the  orbit. 


At  the  root  of  the  neck  it  is  often  difficult  to  make  certain  whether 
the  injury  has  been  to  the  carotid,  the  first  part  of  the  subclavian, 
the  inferior  thyroid,  or  the  vertebral  artery.     I  ha^'e  seen  the  difficulty 

9 


130     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

in  the  case  of  all  these  vessels  only  cleared  np  b)^  operative  exploration. 
When  the  injury  is  purely  arterial,  the  softness  of  a  systolic  murmur 
may  suooest  the  vertebral  as  the  injured  vessel ;  but  little  faitli  can  be 
put  in  such  a  diagnosis.  When  the  lesion  is  arterio-venous,  the  dilli- 
culties  are  far  greater,  not  only  on  accoinit  of  the  widespread  area  over 
which  the  mm-mur  may  be  audible,  but  still  more  by  reason  of  the 
transmission  of  the  characteristic  thrill  from  a  minor  branch  to  the 
current  in  the  main  vein. 

The  following  case  illustrates  well  the  difficulties  which  may 
attend  the  establishment  of  a  correct  diagnosis  Avhcn  multii^le 
wounds  are  present. 

Case  12. — Multiple  -wounds  from  a  bomb  explosion.  Ax-terio-venous 
injuries  to  vessels  of  neck  and  axilla. 

An  officer  was  admitted  to  a  hospital  on  the  Ihies  of  coniniiniication  on 
the  seventh  day  after  being  wounded  by  a  number  of  fragments  of  a  bomb. 
He  was  still  suffering  from  the  effects  of  severe  shock.  Two  small  wounds 
were  situated  over  the  course  of  the  right  common  carotid  artery,  and  one 
over  the  anterior  axillary  fold. 

A  pulsating  ha^matoma  was  present  in  the  lower  part  of  the  neck,  and  over 
this  a  purring  thrill  was  marked,  and  a  loud  arterio-venous  bruit  was  audible. 
The  machinery  murnuir  was  conducted  over  the  entire  area  of  the  chest, 
but  not  to  the  head.  The  murmur  over  the  axilla  was  somewliat  different 
in  character,  and  the  systolic  element  was  widely  conducted  along  the  coui'se 
of  the  brachial  artery.  The  heart's  apex  was  in  the  nipple  line,  the  sounds 
were  audible  distinct  from  the  adventitious  bruit.  The  man's  right  hand  was 
shattered. 

The  patient  was  kept  at  rest,  but  he  picked  up  slowly,  and  three  weeks 
later  a  probe  was  passed  into  a  small  opening  at  the  posterior  margin  of  the 
sternomastoid,  on  account  of  the  persistence  of  a  high  temperature.  This 
procedure  was  followed  by  haemorrhage  of  a  leaking  character,  and  on  the 
evening  of  the  same  day  it  was  considered  advisable  to  deal  with  the 
supposed  wound  of  the  carotid.  An  exploration  made  by  Major  Copeland, 
however,  showed  the  aneurysmal  sac  to  lie  behind  the  great  vessels,  and 
that  the  wound  was  really  one  of  the  inferior  thyroid  artery  and  vein.  I 
think  it  was  quite  impossible  to  have  made  a  correct  diagnosis  in  this 
instance  except  by  operative  exploration. 

The  bruits  characteristic  of  vascular  wounds  are  well  marked  in 
the  neck,  and  discover}'-  of  these  may  lead  to  the  detection  of  a  lesion 
which  otherwise  would  have  passed  unnoticed.  Conduction  of  the 
systolic  murmur  to  the  cardiac  apex  is  not  common  ;  but  I  have 
noticed  it  in  a  few  cases,  and  the  presence  of  such  a  bruit  would 
suggest  that  examination  of  any  minute  or  multii^le  wounds  of  the 
neck  should  be  made. 

Amongst  injuries  of  the  carotid  arteries  followed  by  the  develop- 
ment of  traumatic  aneurysms,  severe  primary  ha-morrhage  was  noted 
in  onl)'-  twelve.  The  nature  of  the  wounds  of  the  soft  parts  which 
accompanied  these  cases,  and  which    has    been  already  referred  to, 


VESSELS    OF    THE   NECK 


\:n 


sufFiciently  explains  this  observation,  as  also  the  experience  that,  when 
haemorrhage  did  ocenr,  it  was  readily  controlled  by  a  pad  and  bandage, 
or  ceased  spontaneously.  When  the  track  of  the  missile  has  crossed 
the  larynx  or  trachea,  or  the  pharynx  or  oesophagus,  the  bleeding  may 


Fig.   37. — Arterial  aneurysm  of  external  carotid  artery. 

be  from  the  mouth,  or  blood   may  pass   down  into  the  air-passages 
or  the  stomach. 

Extravasation  into  the  tissues  of  the  neck  takes  place  mainly 
along  the  line  of  the  vascular  cleft,  but  its  direction  may  be  influenced 


132     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

by  that  of  the  track  of  the  missile,  and  considerable  subciitancons 
ecchymosis  is  not  rare  ;  the  ccchyniosis  tends  to  spread  by  graA'itation 
downA\ards  o^'er  the  front  of  the  chest,  or  o^'er  the  shoidder. 

COMPLICATIONS. 

Secondary  Haemorrhage. — ^This  complication  is  met  with  in  some 
degree  of  frequency.  Thus,  among  66  instances  of  perforating  lesions, 
secondary  bleeding-  occurred  in  15.  It  formed  the  indication  for 
operative  intervention  in  14  cases,  and  in  3  it  proved  the  actual 
cause  of  death. 

As  in  other  situations,  the  occurrence  of  this  complication  is 
usualty  to  be  traced  to  infection  of  the  wound ;  but,  as  has  been  pointed 
out  already,  the  wounds  in  the  patients  who  siu'vive  are  of  a  type  which 
frequently  escapes  infection.  In  two  of  the  fatal  cases  a  streptococcic 
and  an  anaerobic  infection  respectively  were  responsible  for  the 
accident,  but  in  two  others  there  was  no  reason  to  refer  the  bleeding 
to  infection.  Three  of  these  cases  are  of  sufficient  interest  to  merit 
brief  relation. 

Case  13. — Arteriovenous  haematoma.  Anaerobic  infection.  Secondary 
haemorrhage.     Death. 

The  patient  was  wounded  two  days  prior  to  admission  ;  there  was  no 
information  as  to  the  occurrence  of  primary  haemorrliage,  but  the  patient 
was  ill  and  very  ansemie.     Temperature  101°  ;    pulse  104. 

A  circular  wound  two  and  a  half  inches  in  dianzeter  existed  at  the 
posterior  border  of  the  sternomastoid,  two  inches  above  the  clavicular 
origin  of  the  muscle.  A  small  entrance  wound  at  the  back  of  the  neck  was 
closed.  From  the  wound  a  dark  brown  discharge  with  a  strong  faecal  odour 
was  escaping  ;  the  nurse  indeed  said  that  'faeces'  were  coming  out  of  the 
neck.     B.  a'erogenes  capsulatus  was  cultivated  from  the  fluid. 

Four  days  after  the  reception  of  the  wound  a  sudden  severe  secondary 
haemorrhage  took  place.  This  was  arrested  by  plugging  the  wound  with 
gauze  soaked  in  adrenalin.  On  removal  of  the  plug  the  next  day  some 
pulsation  was  noticed,  and  auscultation  revealed  the  presence  of  an  arterio- 
venous bruit.  Shortly  afterwards  the  patient  became  hemiplegic,  and  he 
died  on  the  sixth  day. 

The  right  side  of  the  neck  is  shown  in  Fig.  38.  The  opening,  still 
occupied  by  blood-clot,  is  exposed,  and  leads  down  to  an  aperture  in  the 
internal  jugular  vein  ;  the  wound  in  the  artery  was  not  exposed.  No 
laminated  cavity  had  been  formed  ;  hence  the  condition  was  still  that  of 
an  arterio-venous  haematoma,  in  which  the  rare  accident  of  acute  infection 
had  occurred.  The  hemiplegia  was  either  thrombotic  or  embolic  in  origin, 
but  unfortunately  no  examination  of  the  brain  was  made. 

Fig.  39  is  of  much  interest  as  illusti-ating  the  size  which  collections  of 
gas  may  reach  in  suitable  situations  in  B.  aerogenes  capsulatus  infections. 
The  large  space  behind  the  pharynx  and  oesophagus  contained  gas  only. 

Case  14. — Carotid-jugular  arterio-venous  wound.  Secondary  haemor- 
rhage in  the  absence  of  obvious  infection. 

A  man  was  admitted  three  days  after  the  reception  of  a  transverse 


VESSELS    OF    THE    NECK 


]  .'}8 


bullet  wound  of  the  neck.  The  aperture  of  entry  half  an  in(!li  below  tlie 
upper  margin  of  the  left  ala  of  the  thyroid  cartilage,  and  the  a|)erture  of  exit 
at  the  margin  of  the  right  trapezius  muscle,  two  and  a  half  inches  above  the 
clavicle,  were  both  nrinimal  in  size,  and  closed. 

The  skin  of  the  left  side  of  the  neck  was  of  an  orange  tint  from  fading 
ecchymosis,  and  there  was  some  general  swelling  of  the  neck,  but  no  localized 
tumour  or  expansile  pulsation.     The  man  was  breathing  qiu'etly,  but  the 


Fig.  38. — A  dissection  of  the  neck,  showing  the  aperture  of  exit  of  a  bullet  track 
crossing  the  course  of- the  right  carotid  artery  and  internal  jiigular  vein,  and  establishing 
a  communication  between  them. 

A  glass  rod  projects  from  the  track,  and  the  blood-clot  seen  in  the  opening  is  in 
direct  continuity  with  the  wound  in  the  vein.  The  arterial  wound  has  not  been 
exposed. 

The  wound  \mderwent  anaerobic  infection,  and  the  patient  died  from  secondary 
liEemorrhage,  associated  with  left  hemiplegia,  on  the  sixth  day.     Lieut. -Colonel  Butler. 


voice  was  hoarse  and  low,  the  latter  fact  being  ascribed  to  recurrent  laryn- 
geal paralysis.  The  pulse  was  120,  of  fair  strength,  and  regular.  On 
auscultation  a  loud  arterio-venous  murmur  was  heard,  most  marked  at 
the  posterior  border  of  the  left  sternomastoid  muscle,  in  wliich  position 
a  bubbling  thrill  was  also  palpable  and  strong. 

The  man  showed  little  distress,  and  for  the  next  four  days  lay  quietly 
in  bed,  the  swelling  of  the  neck  steadily  decreasing.     He  took  food  easily, 


134     GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

breathino-  was  practically  normal,  and  no  suspicion  arose  that  the  vascular 
injury  was  not  settling  down  as  is  usually  the  case. 

At  8  p.m.  on  the  tenth  day  after  the  injury,  without  any  warning, 
about  half  a  pint  of  bright  blood  was  coughed  up.  I  saw  him  at  9  p.m.,  when, 
except  that  he  was  rather  excited,  he  seemed  little  changed.  In  view  of  the 
amount  of  blood  coughed  up,  it  apj^eared  advisable  to  ligature  the  root  of 
the  carotid  artery,  or  possibly  deal  directly  with  the  wound  in  the  vessels. 


Fig.  39. — A  mesial  section  of  the  same  neck.  A  glass  rod  in  the  retropharyngeal 
space  indicates  the  central  portion  of  the  track  of  the  bullet.  The  retropharyngeal 
space  itself  is  highly  distended  by  gas  emanating  from  the  action  of  anaerobic  bacilli, 
but  no  pus  was  present  in  the  space.  The  condition  illustrates  well  the  fact  that  the 
extension  of  the  gas  precedes  that  of  actual  invasion  of  the  tissues  by  the  anaerobes, 
and  renders  the  latter  process  more  easy  and  rapid.     Lieut. -Colonel  Butler. 


Open  ether  narcosis  was  chosen  as  the  anajsthetic ;  nothing  special  was 
noted  in  the  breathing  except  that  the  inspirations  were  shallow  and  the 
patient  went  slowly  under  the  influence  of  the  ana-sthetic.  As  the  first 
incision  was  made,  the  inan  ceased  to  breathe,  and  since  there  was  evidently 
mechanical  respiratorj'  obstruction,  I  opened  the  trachea.  JMuch  fluid  blood 
and  clot  escaped,  but  no  relief  was  afforded,  and  the  man  died. 

At  the  autopsy,  the  trachea  and  all  the  bronchial  tubes  were  found  full 
of  blood  and  clot,  there  was  massive  collapse  of  the  lower  lobe  of  the  right 


VESSELS    OF    THE    NECK  135 

lung,  and  localized  patches  of  collapse  in  both  rijifht  and  left  Iiinf>s.  An 
enlarged  thymus  was  present,  and  some  post-operative  ecchyinosis  of  tlie 
mediastinal  tissues.  Beyond  the  presence  of  some  enlarged  mesenteric 
glands,  no  further  visceral  disease  was  discovered. 

The  condition  of  the  vessels  is  shown  in  Fig.  30,  p.  80.  A  double 
perforation  of  the  vein  and  a  lateral  wound  of  the  carotid  are  present, 
while  the  two  vessels  are  separated  by  the  left  vagus  nerve.  The  latter  has 
been  perforated,  and  beyond  the  blood  which  had  collected  within  the 
confines  of  its  sheath,  no  haemorrhage  of  any  moment  has  taken  place  into 
the  vascular  cleft. 

Case  IS.^Wound  of  superior  thyroid  vessels.  Secondary  haemorrhage. 
Death. 

A  man  was  admitted  two  days  after  receiving  a  bullet  wound.  The 
bullet  struck  the  tip  of  his  nose,  passed  through  the  upper  lip,  wounded  the 
tongue,  and  then  entering  the  sinus  pyriformis,  travelled  vertically  down  the 
neck.     Its  final  resting-place  was  never  localized. 

There  was  considerable  swelling  of  the  right  side  of  the  neck,  and  some 
ecchymosis,  but  no  evidence  of  the  existence  of  an  injury  to  the  carotid 
vessels. 

On  the  third  day  after  admission  two  severe  attacks  of  dyspnoea  and 
some  haemoptysis  occurred.     In  the  second  of  these  the  man  died. 

At  the  autopsy,  the  trachea,  bronchi,  and  lungs  were  swamped  with 
blood,  and  there  was  septic  pneumonic  consolidation  of  both  bases.  Extra- 
vasated  blood  was  present  in  the  neck  and  in  the  anterior  and  middle 
mediastina.  A  large  amount  of  blood  had  also  trickled  down  the  gullet, 
and  the  stomach  Avas  loaded  with  clot.  No  injury  to  the  main  carotid  trunks 
had  occurred,  but  the  thyroid  gland  was  mvich  lacerated,  and  its  capside 
bounded  a  large  ha;matoma. 

Subsequent  examination  of  the  specimen  for  preservation  in  the 
Museum  proved  the  injury  to  be  limited  to  the  branches  of  the  superior 
thyroid  artery.  The  haematoma  was  bounded  by  the  capsule  of  the  thyroid 
gland. 

In  this  instance  again,  the  imeventful  development  of  the  haemorrhage 
was  very  striking.  Until  the  first  attack  of  dyspnoea  the  man  appeared  to 
be  progressing  well,  and  the  moderate  haemoptysis  excited  little  suspicion. 
There  is  no  doubt  that  commencing  infection  influenced  the  occurrence  of 
the  secondary  bleeding,  and  was  perhaps  mainly  responsible  for  it. 

The  gradual  unnoticed  filling  up  of  the  lungs  and  stomach  by  blood 
welling  up  from  the  wound  in  the  fossa  pyriformis,  I  believe  again  to  be 
explained  by  the  presence  of  anaesthesia  in  the  area  of  distribution  of  the 
superior  laryngeal  nerve  consequent  on  the  wound  of  the  pyriform  fossa 
and  larynx. 

Concurrent  Injury  to  Nerves. — -The  two  trunks  obviously  liable 
to  injury  are  the  vagus  and  sympathetic. 

Vagus. — Figs.  30  and  44  illustrate  well  a  class  of  injury  to  Avhich 
the  pneumogastric  is  liable,  in  common  with  other  nerves  ;  in  each 
the  nerve  has  been  perforated  and  haemorrhage  has  occurred  within  its 
sheath.  In  both  the  nerve  takes  part  in  the  formation  of  the  channel 
of  communication  between  the  arterj''  and  vein.  It  might  be  thought 
that  a  lesion  of  this  character  and  extent  would  give  rise  to  symptoms 


130     GUNSHOT    INJUIilES    TO    THE    BLOOD-VESSELS 

such  as  great  disturbance  of  the  pulse-rate,  or  variation  in  the  rate  and 
case  of  rcsi)iration  ;  but  although  both  cases  ended  fatally,  one  from 
secondar}^  hannorrhagc.  the  other  from  septic  infection,  in  neither  was 
the  injury  suspected  during  life.  This  being  the  case — and  the  obser- 
vation is  in  consonance  with  the  results  of  physiological  experiment — 
it  must  be  assumed  that  many  minor  injuries  to  the  pneumogastric 
nerve,  and  perhaps  many  cases  of  complete  severance,  pass  unrecog- 
nized. In  a  muiiber  of  operations  which  I  have  performed,  and  others 
of  which  I  have  been  a  witness,  I  have  never  met  with  any  totally 
destructive  lesion,  although  in  many  cases  the  nerve  has  been  tied  up 
and  immobilized  by  the  scar  tissue  of  the  wound  track,  or  in  others 
had  acquired  a  solid  adhesion  to  the  carotid  artery  which  required 
dissection  with  the  knife  to  separate  it.  The  average  pulse-rate  in  a 
large  number  of  injuries  to  the  carotid  vessels  which  I  have  examined 
amounted  to  88,  with  extremes  of  62  and  120.  In  two  cases  in  which 
grave  infection  was  j:)resent,  the  rate  reached  120,  but  the  vagus  could 
not  be  held  responsible  for  these. 

With  regard  to  any  general  respiratory  difhcidties,  again,  I  have 
never  detected  any  indication  of  disturbance  of  vagal  function  ;  but 
local  laryngeal  symptoms  are  not  uncommon,  especially  if  the  missile 
has  penetrated  or  traversed  the  larynx.  The  most  common  sign  is 
weakness  or  hoarseness  of  the  voice  ;  this  is  usually  temporary,  and 
may  be  referred  in  most  instances  to  laryngeal  concussion,  or  the  local 
influence  of  the  injury.  In  other  instances  definite  unilateral  abductor 
jiaralysis  is  observed,  and  this  both  in  injuries  to  the  upper  and  lower 
segments  of  the  artery.  This  latter  observation  shows  that  abductor 
paralysis  may  follow  injury  to  the  trunk  as  well  as  local  injury  to  the 
recurrent  lar\''ngeal  branch,  so  that  the  sign  is  of  little  use  in  localizing 
the  site  of  the  arterial  lesion. 

The  insidious  manner  in  which  blood  may  trickle  through  the 
larynx  and  flood  the  air-passages  has  already  been  referred  to,  and 
there  seems  reason  to  believe  that  this  may  depend  on  anaesthesia  of 
the  area  supplied  by  the  superior  laryngeal  nerve,  and  abolition  of  the 
cough  reflex. 

Cervical  Sympathetic. — Evidence  of  injury  to  the  sympathetic 
chain  is  often  present,  and  in  contrast  to  what  occurs  in  the  case  of  the 
vagus,  it  can  scarcely  escape  recognition.  General  flattening  of  the 
face,  sunken  eyeball,  slight  ptosis  and  narrowing  of  the  palpebral 
fissure,  contracted  pupil,  and  absence  of  sweating  on  the  affected  side 
of  the  head,  are  met  with  in  varjdng  degree  in  more  than  12  per  cent 
of  all  the  cases  of  carotid  aneurysm.  In  many  instances  the  signs 
persist  for  months,  and  in  some  they  are  no  doubt  permanent.  They 
are  met  with  whichever  jDart  of  the  carotid  is  wounded.  In  some 
instances  the  signs  are  rather  those  of  irritation  than  of  ablation  of 


VESSELS    OE    THE    NECK  l.*37 

function  ;  in  such  the  paralytic  signs  may  be  less  marked,  the  eyeball 
may  be  prominent  rather  than  sunken,  and  hy))eridrosis  may  be 
present.  In  this  relation  it  is  of  interest  to  note  that  the  same  suscep- 
tibility on  the  part  of  the  sympathetic  is  sometimes  exhibited  in  the 
form  of  unilateral  flushing  and  sweating  of  the  stimulated  side  after 
operations  on  the  carotid  vessels.  The  frequency  with  which  signs  of 
injury  to  the  sympathetic  are  discovered  is  due  to  their  obvious 
character,  but  a  further  factor  of  a  mechanical  nature  of  considerable 
importance  enters  into  the  question  of  the  frequency  of  these  injuries. 
The  vagus  lies  in  the  comparatively  loose  and  roomy  vascular  cleft, 
and  is  capable  of  very  considerable  displacement  either  laterally  or  in 
a  forward  direction  ;  while  the  sympathetic  chain  lies  in  intimate 
contact  with  the  prevertebral  layer  of  the  cervical  fascia,  and  in  addi- 
tion is  more  or  less  immobilized  by  the  branches  which  pass  laterally 
from  its  ganglia.  Hence  it  is  a  comparatively  fixed  and  immobile 
structure,  more  liable  to  suffer  the  full  force  of  any  missile  which  may 
traverse  its  course. 

The  remaining  nerve  lesions  are  of  less  interest ;  but  injuries  to 
the  hypoglossal  and  spinal  accessory  nerves  are  met  with,  especially 
in  connection  with  lesions  of  the  external  or  internal  carotid  arteries. 
Any  of  the  branches  of  the  cervical  plexus  may  be  damaged,  and  to 
low  injuries  of  the  carotid  may  be  added  signs  of  contusion  or  division 
of  one  or  more  of  the  cords  of  the  brachial  plexus.  Instances  of  all 
these  lesions  are  not  uncommon.. 

CEREBRAL     COMPLICATIONS. 

It  will  be  convenient  to  deal  here  with  the  whole  question  of 
cerebral  complications,  whatever  be  the  nature  of  the  lesion  of  the 
carotid  vessels  they  follow,  since  there  is  no  essential  difference  in  the 
consequences  observed. 

The  development  of  cerebral  symptoms  may  be  a  sequence  of 
uncomplicated  wound  of  the  common  or  internal  carotid  artery  ;  of 
contusion  ;  of  local  occlusion  of  the  vessel  by  thrombosis  ;  of  throm- 
bosis extending  Avidely  into  the  cerebral  vessels  ;  of  embolism  ;  or  of 
surgical  occlusion  of  the  trunks.  Examples  of  all  these  conditions  and 
sequences  of  events  are  given  below,  but  we  are  practically  ignorant 
of  the  factors  which  may  determine  the  occurrence,  or  influence  the 
gravity  of  the  symptoms,  in  any  individual  case. 

Certain  conditions  which  certainly  influence  the  incidence  of 
cerebral  symjDtoms  may  be  first  mentioned  ;  these  are  a  considerable 
reduction  in  the  total  volume  of  blood  in  the  general  circulation  follow- 
ing hcTmorrhage,  and  the  co-existence  of  a  general  toxaemia  or  septi- 


138     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

cscmia.  Of  other  possible  factors,  such  as  personal  idiosyncrasy, 
variations  jji  the  niode  of  formation  of  the  circle  of  Willis,  the  scheme 
-of  anastomosis  of  the  cerebral  vessels,  the  size  and  shape  of  the  bony 
foramina  by  which  the  vessels  enter  the  skull,  or  the  manner  in 
Avhich  the  nerves  supplying  the  arterial  wall  in  any  individual  case 
may  be  implicated,  we  know  little  or  nothing  ;  while  in  the  class  of 
patients  likely  to  suffer  from  gunshot  injuries,  the  question  of  arterial 
degeneration  seldom  comes  into  consideration. 

No  doubt  can  exist  as  to  the  unfavoiu'able  influence  exerted  by 
the  previous  occurrence  of  a  primary  or  secondary  hn?morrhage,  for 
this  accident  is  seen  not  only  to  be  of  import  in  the  case  of  the  sus- 
ceptible tissue  of  the  brain,  but  also  in  determining  the  degree  of 
muscular  degeneration,  or  even  gangrene,  of  a  limb.  The  same  may 
be  said  with  regard  to  the  ill  effects  of  a  condition  of  general  tox- 
aemia. The  cerebral  complications  Avhich  follow  interruption  of  the 
carotid  circulation  are,  however,  far  more  dramatic  in  onset  and  in 
gravity  than  those  due  to  obstruction  to  the  arterial  sujDply  of  a  limb, 
and  in  view  of  the  special  arrangements  of  the  intracranial  circulation 
Avhich  are  calculated  to  reduce  to  a  minimum  the  danger  of  interruption 
of  any  one  source  of  blood-supply,  they  are  still  more  striking.  It  is 
most  disconcerting  that  one  patient  may  develop  signs  of  hemiplegia 
while  still  ujoon  the  operating  table,  or  detected  as  soon  as  he  recovers 
from  the  anaesthetic,  while  in  others  no  sign  of  any  disturbance  what- 
ever of  the  intracranial  circulation  can  be  discovered.  Putting  upon 
one  side,  moreover,  actual  cerebral  symptoms,  the  opiDortunities  for 
gauging  the  freedom  of  circulation  in  the  carotid  arteries  is  remarkably 
limited.  Decrease  in  volume  of  the  pulse  in  the  branches  of  the 
external  carotid,  such  as  the  temporal  or  the  facial,  may  be  of  some 
aid  ;  yet  the  cross-anastomosis  between  these  vessels  is  so  free  that 
little  weight  can  be  placed  upon  a  diminution  of  strength  of  pulse, 
for  such  diminution  may  be  observed  in  patients  in  whom  no  cerebral 
signs  develop,  inequality  of  the  two  sides  may  not  be  marked  when 
evidence  of  cerebral  disturbance  is  certain,  and  it  may  be  observed 
in  the  subjects  of  arterial  or  arterio- venous  aneurj'^sm  in  whom  the 
vascular  obstruction  is  not  more  than  very  partial  in  its  nature.  With 
regard  to  examination  of  the  circulation  in  the  branches  of  the  internal 
carotid  artery,  Mr.  Fisher  has  been  kind  enough  to  investigate  for  me 
the  fundus  oculi  in  a  number  of  men  whose  common  carotid  has  been 
tied  fourteen  to  twenty-one  days  previously  ;  in  none  could  evidence 
of  vascular  disturbance  be  detected. 

These  observations  raise  the  further  question  as  to  whether  the 
extreme  cerebral  anaemia  depends  solely  on  the  local  obstruction  of 
one  of  the  sources  of  blood-supply,  or  whether  to  the  local  obstruction 
there  is  sui^eradded  a  condition  of  vasoconstriction  or  vascular  spasm 


VESSELS    OF    THE    NECK  139 

which  augments  and  renders  more  persistent  and  harmful  the  anaemia 
induced  by  the  occhision  of  the  carotid. 

In  the  absence  of  evidence  of  vaso-contraction  as  an  actual 
response  to  the  stimulus  afforded  by  a  local  injury  to  the  vessel,  it 
must  be  assumed  that  the  lowered  blood-pressure — a  prominent 
feature  if  primary  haemorrhage  has  been  abimdant — combined  with 
a  deficient  total  volume  of  blood  in  the  circulation,  are  the  actual 
factors.  The  cerebral  arteries,  being  more  or  less  completely  emptied 
by  the  sudden  interruption  of  their  main  blood-supply,  contract  even 
to  the  degree  of  obliteration  of  their  lumen,  and  the  remaining  blood- 
pressure  proves  insufficient  to  overcome  the  muscular  resistance 
offered  to  their  dilatation.  This  explanation  obviously  obtains,  even 
if  in  lesser  degree,  when  the  lowered  blood-pressure  depends  upon 
shock  alone. 

Some  observations  on  the  condition  which  has  been  described 
and  designated  as  '  vascular  stupor '  (see  p.  14),  occurring  as  a  result 
of  contusion  of  the  vessels  of  the  extremities,  has  also  a  bearing  on 
this  question,  since  in  that  condition  the  bloodlessness  of  the  peri- 
pheral circulation  must  be  secondary  to  the  local  obstruction,  which 
depends  upon  extreme  and  persistent  local  contraction  of  the  artery 
at  the  site  of  the  injury. 

The  observations  of  Leriche  and  Ileitz,*  although  apparently 
based  upon  an  incomplete  appreciation  of  the  actual  anatomical 
arrangement  and  distribution  of  the  nerve-supply  to  the  blood-vessels, 
yet  furnish  experimental  evidence  of  the  vaso-constrictor  effect  pro- 
duced by  interruption  of  the  continuity  of  the  nervous  chain  in  the 
case  of  the  limbs,  as  seen  after  the  performance  of  Leriche's  operation 
of  perivascular  sympathectomy  (see  p.  56).  Unfortunately,  however, 
these  phenomena  cannot  be  considered  applicable  in  the  case  of  the 
cerebral    circulation. 

If  the  theory  of  lowered  blood-pressure  and  an  insufficient  total 
volume  of  blood  be  the  correct  explanation,  it  is  obvious  that  the 
correct  method  of  "treatment  is  the  transfusion  of  blood,  as  the  most 
efficient  means  of  both  heightening  the  pressure  and  supj)lying  a 
proper  supplement  to  the  blood  content  of  the  body.  As  far  as  I 
know,  this  procedure  has  not  until  now  been  adopted. 

Nature  of  the  Cerebral  Symptoms  observed. — little  special  des- 
cription needs  to  be  given  of  these.  They  may  vary  greatly  in 
severity  and  distribution.  In  the  most  severe  cases  the  patient  may 
become  at  once  unconscious,  and  later  comatose,  the  onset  sometimes 
being  accompanied  by  restlessness  or  struggling.  In  other  instances 
the  loss  of  consciousness  may  be  short,  or  mere  drowsiness  and  mental 

*  Lyon  Chirurgicale,  xiv.  No.  4,  p.  754. 


14-0      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 


slowness  may  take  its  place.  The  loeal  paralytic  signs  may  vary  in 
a  similar  manner  :  thus  there  may  be  temporary  or  permanent  ajihasia, 
paresis  or  paralysis  of  the  limbs,  temporary  or  permanent  loss  of  power 
over  the  sphincters.  In  some  cases  aphasia,  or  loss  of  motor  power  in 
one  limb  only,  may  develop.  In  monoplegias,  the  upper  extremity 
is  the  more  frequently  affected  ;  the  paralysis  may  be  complete,  or 
disturbances  of  sensation  or  loss  of  muscular  sense  may  be  the  main 
feature.  Great  variations  are  seen  in  the  distribution  and  severity 
of  the  sensory  disturbances,  and  all  these  symjjtoms  may  be  evanescent, 
temporary,  or  permanent  in  different  instances. 

The  varying  circumstances  under  which  cerebral  complications 
may  follow  injuries  to  the  carotid  arteries  will  be  most  satisfactorily 
set  forth  by  a  brief  recital  of  some  illustrative  cases. 

Case  16. — Injury  to  the  left  common  carotid  artery.  Thrombosis 
extending  into  the   internal  carotid  trunk.      Right  hemiplegia.      (Under   the 

charge  of  Captain  Alan  Curry,   to    whom  I 
am  indebted  for  the   notes   and  specimen.) 

Pte.  R.  was  admitted  into  a  casualty 
clearing  station  suffering  with  severe  shell 
wounds  of  both  legs,  and  a  compound  frac- 
ture of  the  left  tibia  and  fibula.  A  small 
wound  of  entry  was  present  over  the 
thyroid  cartilage  in  the  mid-line  of  the 
neck.  The  man  was  drowsj-  and  could  not 
speak,  there  was  right  hemiplegia,  increase 
of  the  right  knee-jerk,  no  ankle-clonus,  and 
an  extensor  response  to  stimulation  of  the 
sole.  Temperature  99°.  Pulse  110.  No 
swelling  or  bruit  could  be  detected  in  the 
neck,  and  the  temporal  pulses  w^ere  equal. 
The  wounds  were  cleansed  and  dressed, 
and  for  the  next  two  days  the  patient 
appeared  to  be  pi'ogressing  satisfactorily, 
but  on  the  third  day  the  left  leg  became 
gangrenous  as  a  result  of  a  wound  of  the 
posterior  tibial  artery,  and  was  amputated. 
Death  occurred  on  the  fourth  day.  At 
the  autopsy  a  w^ound  of  the  left  common 
carotid  half  an  inch  below^  the  bifurcation 
was  discovered.  The  fragment  of  shell 
which  had  occasioned  the  wound  projected 
into  the  opening  in  the  wall  of  the  vessel, 
while  it  was  surrounded  externally  by  a 
small  incipient  aneurysmal  sac.  On  laying 
the  artery  open  it  was  found  that  a  throm- 
bus completely  obliterated  the  lumen  of  the 

internal    carotid    branch,    and   partiallj^    obstructed    the     external    carotid 

{Fig.  40).  •  The  internal  jugular  vein  was  uninjured. 

There  was  well-marked  softening  of  the  basal  ganglia  of  the  left  side 

of  brain,  but  neither  intracranial  thrombosis  nor  embolism  was  present. 


Fig.  40. — Wound  of  left 
common  carotid  artery.  Local 
thrombosis  of  internal  carotid 
and  partial  obstruction  of  ex  • 
ternal  carotid.  Localized  exter- 
nal clot,  and  fragment  of  shell 
(A)  projecting  into  wound. 


VESSELS    OF    THE    NECK 


141 


Case  17. — Complete  severance  of  continuity  of  the  right  internal 
carotid  artery.  Local  thrombosis.  Left  hemiplegia.  (Under  tlie  cliargc  of 
Captain  C   h.    Kkynes,   to  whom   I  am   indebted  lor  the  notes.) 

Pte.  L.  was  admitted  into  a  casualty  clearino;  station  with  a  wound  of 
the  neck.  The  bullet  had  entered  over  the  left  angle  of  the  mandible,  and 
emerged  an  inch  and  a  half  below  the  tip  of  the  right  mastoid  process. 
The  rainus  of  the  jaw  was  fractured.  There  was  some  respiratory  distress, 
inability  to  swallow,  and  the  pulse  was  rapid  and  feeble.  No  external 
haemorrhage  was  occurring. 

On  the  evening  of  the  second  day  the  respiratory  distress  increased 
and  the  pulse  became  more  feeble.  It  was  considered  advisable  to  perform 
tracheotomy,  and  the  operation  afforded 
the  patient  considerable  relief.  On  the 
night  of  the  third  day  he  became  hemi- 
plegic,  the  temperature  rose  to  105°,  and 
death  occurred  on  the  evening  of  the  fourth. 

At  the  autopsy,  the  right  internal  caro- 
tid artery  was  found  to  have  been  com- 
pletely divided  at  the  level  of  the  aperture 
of  exit.  An  ante-mortem  clot  occluded  the 
lumen,  extending  downward  for  two  inches 
and  upward  into  the  sigmoid  bend  in  the 
cavernous  sinus.  No  thrombus  or  embolus 
was  discovered  in  the  cerebral  vessels  ;  and 
beyond  pallor,  no  naked-eye  change  was 
detected  in  the  brain. 

Case  18. — -Minimal  contused  -wound  of 
the  common  carotid  artei-y.  Spreading 
thrombosis.  (Under  the  charge  of  Captain 
H.  B.  Walker,  to  whom  I  am  indebted  for 
the  notes  and  the  specimen — Fig.  41). 

Pte.  D.  was  brought  to  a  casualty  clear- 
ing station  shortly  after  receiving  several 
wounds.  A  wound  of  entry  the  size  of  a 
halfpenny  was  present  in  the  right  cheek, 
also  a  small  perforating  wound  of  the  right 
pinna,  and  a  superficial  wound  over  the 
right  mastoid  process. 

When  taken  to  the  theatre  to  have  the 
wounds  cleaned  up,  the  man  was  drowsy, 
but  no  actual  paralysis  was  noted.  Pulse 
72.  Temperature  98°.  Some  blood-clot  was 
present  around  the  nostrils.  A  fragment  of 
shell  the  size  of  a  walnut  was  removed  from 
the  right  pterygoid  fossa,  also  some  frag- 
ments of  bone  from  the  fractured  mandible. 
No  serious  haemorrhage  occurred. 

The  patient  remained  in  a  drowsy  condition,  with  a  pulse  of  60  and 
temperature  of  97°,  but  his  condition  did  not  at  first  give  rise  to  any  special 
anxiety.  During  the  night  he  became  restless  and  tore  off  his  dressings,  and 
on  the  morning  of  the  second  day  he  had  become  comatose.  The  pulse 
was  irregular,  without  periodicity,  at  times  full  and  slow,  at  others  rapid 
and  feeble.     The  breathing  was  slow  and  stertorous.     The  right  pupil  was 


Fig.  41.  —  Contusion  and 
minimal  woimd  of  common 
carotid.  Thrombosis  of  internal 
carotid,  extending  into  cerebral 
vessels.  The  minute  perfora- 
tions are  indicated  by  the  two 
dark  spots  at  the  upper  part  of 
the  carotid  trunk. 


142      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

dilated  and  fixed,  the  left  narrowly  contraeted  :  there  was  extensor  spasm 
of  the.  limbs,  with  ])ronation  of  the  arms.  The  abdominal  reflexes  were 
absent  ;  sjiastieity  of  the  limbs  ])revented  elicitation  of  the  tendon  reflexes. 
The  richt  i)lantar  reflex  was  extensor,  the  left  flexor. 

A  provisional  diagnosis  of  fracture  of  the  base  of  the  skull,  with  possible 
middle  meningeal  hiemorrhage,  was  arrixed  at,  but  the  condition  of  the 
patient  was  such  that  a  projected  exploration  was  abandoned  and  lumbar 
pimeture  substituted.  Three  drachms  of  clear  fluid  imder  no  great  pressure 
were  withdrawn.  Improvement  followed  this  procedure,  the  pulse  became 
slow  and  full,  and  the  breathing  less  stertorous.  As  a  last  hope  the  middle 
meningeal  area  was  then  explored  with  the  aid  of  local  anaesthesia.  The 
result  was  negative  ;  as  the  dura  showed  no  pulsation,  it  was  opened,  but 
no  sign  of  congestion  or  of  pressure  was  discovered.  ; 

Death  followed  shortly  after  the  operation.  No  trace  of  injury  to 
either  brain  or  skull  was  found  on  post-mortem  examination.  The  right 
internal  carotid  was  noticed  to  have  already  become  much  lai'ger  than  the 
left,  and  the  latter  was  distended  with  ante-mortem  clot.  The  left  middle 
cerebral  artery  was  also  filled  with  clot,  and  downwards  the  thrombus 
extended  to  about  ^  in.  below  the  lateral  mass  of  the  atlas.  Opposite  this 
process  two  small  perforations,  apparently  the  result  of  the  vessel  having 
been  nipped  between  the  fragment  of  shell  and  the  bone,  indicated  the 
initial  cause  of  the  thrombosis. 

Case  19. — Wound  of  the  right  external  carotid  artery.  Contusion  and 
extending  thrombosis  of  left  internal  carotid  artery.  (Under  tlie  care  of 
Captain  H.  Lawson  Whale,  to  whom  I  am  indebted  for  the  notes.) 

Pte.  S.  was  admitted  into  a  stationary  hospital  with  a  wound  at  the 
junction  of  the  right  ala  nasi  with  the  cheek,  the  further  direction  of  the 
track  being  apparently  toward  the  left  mastoid  process.  Immediately 
after  admission,  and  before  there  was  time  to  remove  his  clothes,  a  copious 
and  persistent  haemorrhage  occurred  from  the  patient's  mouth.  It  was 
doubtful  from  which  internal  maxillary  artery  the  blood  came,  but  as 
bleeding  was  checked  by  pressure  over  the  right  common  carotid,  the 
external  carotid  of  that  side  was  promptly  ligatured.  Within  three  hours 
from  the  time  of  operation,  right  hemiplegia  was  noted,  and  the  man  became 
comatose.  The  patient  was  seen  by  Colonels  Gordon  Holmes  and  Percj^ 
Sargent,  who  agreed  that  the  slow  pulse  and  accompanying  signs  suggested 
pressure  from  intracranial  haemorrhage,  but  considered  that  the  patient's 
condition  negatived  surgical  intervention. 

Death  occurred  a  few  hours  later.  At  the  autopsy,  the  right  external 
carotid  artery  was  found  thrombosed  for  an  inch  beyond  the  point  ligatured. 
On  the  left  side  of  the  neck  a  shrapnel  ball  was  discovered  lying  in  the  fork 
of  bifurcation  of  the  common  carotid  ;  from  this  spot  a  continuous  thrombus 
extended  into  the  circle  of  Willis  and  into  the  branches  of  tlie  middle  cerebral 
artery  as  far  as  they  could  be  traced  into  the  fissure  of  Sylvius. 

The  above  four  cases  afford  post-mortem  evidence  of  the  nature 
of  the  primary  lesion  to  the  vessels,  and  of  its  ultimate  consequences. 
It  will  be  observed  that  in  the  first  two,  local  thrombi  developed  at 
the  site  of  the  arterial  vfound  ;  hence  the  obstruction  corresj^onds 
in  nature  with  that  which  might  have  followed  the  application  of  a 
ligature.      In    the    second    case,    the    occurrence    of    septic    infection 


VESSELS    OF    THE    NECK  143 

cannot  be  disregarded  as  an  influencing  factor,  and  in  a  less  degree 
this  remark  aj^plies  to  the  first  case  also.  The  fact  that  symptoms  are 
accompanied  by  a  high  temperature  must  not,  however,  be  estimated 
too  highly  as  a  sign  of  septic  infection,  since  such  rises  commonly 
attend  the  development  of  arterial  thrombosis. 

The  third  and  fourth  cases,  in  which  continuous  thrombi  extended 
to  the  middle  cerebral  artery,  obtain  special  diagnostic  interest.  Both 
exhibited  cerebral  symptoms  indistinguishable  from  those  of  severe 
intracranial  pressure  such  as  may  accompany  the  occurrence  of  a 
haemorrhage;  hence  in  one  an  exploration  was  performed,  and  in  the 
other  taken  into  consideration.  I  have  seen  the  same  course  taken 
in  another  case. 

In  a  paper  published  in  1916,*  a  series  of  instances  of  injury  to 
the  carotid  arteries  accompanied  by  cerebral  comjDlications  is  dis- 
cussed, and  the  cerebral  symptoms  are  ascribed  to  embolism.  In  all  of 
these  the  diagnosis  was  made  on  clinical  grounds  alone,  and  it  appears 
clear  in  many  of  them  that  the  nature  of  the  symptoms  and  their 
localized  character  warranted  the  conclusion  then  arrived  at.  The 
post-mortem  findings  that  we  now  have  at  our  disposal,  however, 
suggest  that,  in  some  of  the  more  severe  and  complete,  extending 
thrombosis  was  an  equally  probable  explanation  of  the  symptoms. 

Some  of  these  cases  are  again  quoted  ;  they  are  especially  valuable, 
as  Colonel  Gordon  Holmes  kindly  made  the  neurological  examinations 
and  notes,  and  in  some  of  them  the  further  progress  can  now  be 
recorded.  In  those  cases  in  which  a  non-perforating  lesion  was 
assimied,  the  distinction  was  made  on  the  absence  of  bruit,  ^^^u'ring 
thrill,  pidsating  tumour,  or  the  occurrence  of  secondary  haemorrhage. 
Increased  experience,  however,  shows  that  the  presence  or  absence  of 
these  signs  does  not  furnish  sufficient  grounds  for  establishing  the 
distinction,  and  that  in  any  of  the  eases  minimal  wounds,  or  even 
more  extensive  lesions,  may  have  existed. 

Case   20. — Non-penetrating  lesion  of  the  left  common  carotid  artery. 

The  patient  was  admitted  into  No.  1  Canadian  General  Hospital 
under  the  care  of  I.ieut. -Colonel  Finley  on  Dee.  12,  1915,  having  probably 
been  wounded  a  day  or  two  earlier.  He  thinks  the  bullet  entered  by  his 
mouth,  and  this  statement  is  supported  by  the  presence  of  scarring  of  the 
lip  and  fractures  of  the  left  premolar  and  incisor  teeth.  The  wound  of  exit 
is  situated  two  inches  to  the  left  of  the  fifth  and  sixth  cervical  spinous 
processes.  Consciousness  was  not  lost  at  the  time  of  the  accident,  and  the 
man  walked  a  mile  to  a  first-aid  post  with  full  power  over  his  limbs.  Twelve 
hours  later,  during  the  night,  he  suddenly  lost  power  in  the  right  iipper  and 
lower  extremities,  and  his  speech  became  affected.     No  fit  occurred. 

When  admitted  to  hospital,  there  was  complete  flaccid  palsy  of  the 

*  Lancet,  191G,  ii,  Sept.  23,  p.  543. 


U4      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

right  iipjier  extremity,  tlie  left  lower  extremity  could  only  be  moved  slightly, 
and  aphasia  was  complete.  Dm-ing  the  succeeding  fortnight  some  improve- 
ment took  place,  and  the  condition  on  Dec.  21  was  as  follows  : — 

"  The  wound  of  exit  is  healed  ;  there  is  slight  fullness  over  the  left 
carotid  artery,  but  no  abnormal  pulsation,  thrill,  or  miu'mur.  Pulsation  in 
the  temporal  vessels  is  equal.  There  is  some  dilficulty  of  speech,  but  the 
patient  answers  questions  rationally.  Pupils,  both  circular,  and  react  to 
light ;  but  the  left  is  much  smaller  and  ?  no  dilatation  to  shade  and  no  skin 
sympathetic  reflex.  The  left  eye  is  sunken  and  the  palpebral  fissure  narrowed. 
Both  sides  of  the  face  are  equally  dry.  There  is  considerable  weakness  of 
the  right  facial  muscles,  and  the  tongue  is  protruded  to  the  right.  Motor 
system  :  Right  upper  extremity  somewhat  wasted,  especially  distally  ;  all 
inovements  are  possible  but  much  weaker  than  on  the  left  side,  distally 
proportionately  more  so.  Slight  rigidity  of  shoulder  and  elbow.  No  ataxia. 
Right  lower  extremity,  all  movements  possible  but  weaker  than  left.  No 
rigidity.  Reflexes  : — Arm -jerks  :  R.  +  +  ;  L.  normal.  Knee-jerks  : 
R.  +  +  ;  L.  normal.  Ankle-jerks  :  R.  +  +  ;  L.  normal.  Right  ankle- 
clonus.  Abdominal  reflex:  R.  -  ;  L.  f.  Plantar  reflex:  R.  extensor; 
L.  flexor.  Sensation  : — Touch  unaffected.  Pain  unaffected.  Position  : 
R.     diminished.     Form  lost.     Diagnosis  : — Cortical   embolism." 

Seven  months  later  the  following  note  was  made  on  the  occasion  of  the 
man's  discharge  from  the  army  as  permanently  unfit  :  "  Aphasic  ;  dys- 
arthria. R.  facial  paral^^sis.  R.  ann  useless.  Paresis  of  left  leg,  but  this 
is  steadily  improving." 

Case  21. — Non-penetrating  injury  of  the  right  common  carotid  artery. 

The  patient  was  admitted  into  No.  1  Canadian  General  Hospital  under 
the  care  of  Lieut. -Colonfx  Finley.  He  had  been  wounded  probably  on 
Dec.  18.  A  superficial  glancing  wound  of  the  scalp  was  present  in  the 
left  occipital  region,  with  no  apparent  injury  to  the  bone  (x  rays)  ;  also 
a  small  irregular  wound  at  the  middle  of  the  posterior  border  of  the  right 
sternomastoid  muscle.  Temporal  pulses  equal.  Nothing  abnormal  pal- 
pable in  course  of  carotid.  Three  days  after  infliction  of  the  injuries  left 
hemiplegia  suddenly  occurred.  No  fit.  On  Dec.  20  the  man  became 
incontinent  and  the  left  limbs  spastic  ;  also  some  rigidity  of  the  right  arm 
was  noted.     On  Jan.  21,  1916,  the  condition  Avas  as  follows  : — 

"  The  patient  is  dull  and  stupid,  also  incontinent.  He  complains  of 
sharp  pains  in  the  left  leg.  Pupils  :  R.  smaller  than  L.  ;  the  right  eye  is 
not  sunken,  but  the  palpebral  fissure  is  smaller  than  the  left.  The  right  side 
of  the  face  is  less  greasy  than  the  left.  Much  weakness  of  left  facial  muscles. 
Tongue  protruded  slightly  to  the  left.  Motor  system  : — Left  upper  extrem- 
ity powerless  and  somewhat  rigid.  Joint  changes  have  developed.  Left 
lower  extremity  rigid  ;  the  only  movement  that  can  be  made  is  slight  exten- 
sion of  the  limb  as  a  whole.  Right  lower  extremity  normal.  Reflexes  : — 
Arm -jerk  :  L.  +  +.  Knee-jerk  :  R.  normal  ;  L.  +  +.  Ankle- jerk  :  R. 
normal  ;  L.  +  -f.  Abdominal  :  R.  +  ;  L.  absent.  Plantar  :  R.  flexor  ; 
L.  extensor.  Sensation  : — Touch  :  Definite  loss  on  whole  left  side.  Pinch  : 
Sharper  and  sorer  on  left  side.  Position  :  General  loss  on  left  side.  The 
application  of  cold,  pinching,  and  scraping  causes  more  pain  and  a  greater 
reaction  on  the  left  than  the  right  side.  Diagnosis  : — Embolism  deep  in 
the  right  hemisphere  involving  the  internal  capsule  and  the  lateral  aspect 
of  the  optic  thalamus  (thalamic  syndrome)." 

No  improvement  occurred  before  transference  to  England  two  weeks 
later. 


VESSELS    OF    THE    NECK  145 

Case  22. — Penetrating  wound  of  the  left    common  carotid  artery. 

Patient  was  admitted  into  No.  1  Canadian  General  IIf)spitaI  under  tiie 
care  of  Lieut. -C'oi.onel  Gunn  about  June  8.  He  had  been  wounded 
on  May  21,  1916,  and  had  been  subsequently  trephined,  with  a  negative 
result.  A  gutter  wound  was  present  in  the  scalp  just  above  the  lelt  ])inna, 
also  an  irregular  entry  wound  in  the  left  side  of  the  neck  in  the  superior 
carotid  triangle  at  the  level  of  the  upper  margin  of  the  thyroid  cartilage, 
and  an  exit  wound  at  the  posterior  border  of  the  left  sternomastoid  muscle 
at  about  the  same  level.  Both  wounds  were  caused  by  fragments  of  a  bomb. 
On  June  9  the  patient  was  still  completely  hemiplegic  and  aphasic.  He 
emitted  some  articulate  sounds,  but  could  answer  no  questions,  and  no  pre- 
vious history  was  obtainable.  The  wounds  in  the  neck  were  still  unhealed  ; 
forcible  pulsation  was  noted  over  the  carotid,  but  no  palpable  tumour.  The 
temporal  pulses  were  equal.  On  auscultation,  a  soft  systolic  bruit  was 
audible  over  the  carotid  in  the  line  of  the  wounds.  The  heart  was  of  normal 
size  and  no  murmur  was  audible.  On  June  15  a  severe  secondary  haemor- 
rhage occurred,  and  the  common  carotid  artery  was  ligatured  by  Lieut. - 
Colonel  Hutchinson.  An  extensive  laceration  of  the  vessel  was  discovered 
in  the  upper  third  of  its  course.  The  operation  was  followed  by  an  imme- 
diate slight  improvement  in  the  paralytic  symptoms,  the  next  day  some 
words  could  be  spoken,  and  eight  days  later  some  movements  of  the  leg 
could  be  made.  The  patient  was  shortly  afterwards  transferred  to  England 
still  improving. 

Three  months  later,  "  the  man  was  beginning  to  walk,  and  could  move 
his  arm  and  hand.  His  mental  condition  remained  very  depressed,  and  he 
could  remember  little  of  his  past  history."  At  the  end  of  twelve  months  he 
was  discharged  from  the  army  as  permanently  unfit. 

Case  23. — Non-perforating  injury  to  left  common  carotid  artery. 

Patient  was  admitted  into  the  St.  John's  Ambulance  Brigade  Hospital 
under  the  care  of  Major  Maynard  Smith  in  January,  1916.  He  was 
wounded  on  Jan.  4  by  a  rifle  bullet  which  entered  the  left  side  of  the  neck 
opposite  the  centre  of  the  anterior  border  of  the  sternomastoid  muscle,  and 
passing  obliquely  transversely,  emerged  just  in  front  of  the  right  angle  of 
the  mandible.  The  man  was  not  rendered  unconscious,  and  one  hour  later 
he  lost  power  in  his  right  arm,  and  experienced  for  two  days  much  difficulty 
in  speaking  :  "  Couldn't  say  what  he  wanted  to."  His  lower  extremities 
were  never  affected.  Steady  improvement  took  place,  and  a  week  later 
(June  11)  speech  was  almost  normal,  the  wounds  were  practically  healed,  no 
abnormal  pulsation  .was  palpable  over  the  carotid,  no  bruit  was  audible, 
and  the  temporal  pulses  were  equal.     The  following  note   was  made  : — 

"  Motor  system  : — Right  upper  extremity  :  No  rigidity  ;  all  movements 
of  the  shoulder  and  elbow  are  possible,  but  weaker  than  those  of  the  other 
limb.  Extension  of  the  wrist  can  be  made  occasionally,  but  the  effort  often 
fails  ;  flexion  of  the  wrist  is  not  obtainable  ;  no  movements  of  the  fingers 
can  be  made.  The  lower  extremities  are  normal.  Reflexes  : — Arm-jerk  : 
R.  +  ;  L.  -  .  Knee-  and  ankle-jerks  normal.  Abdominal  :  Right  less 
than  left.  Plantar  :  Flexor.  Sensation  : — Touch  and  pin-prick  unaffected. 
Position  and  form  lowered  as  to  right  hand.  Diagnosis  : — Small  cortical 
embolism." 

Case   24. — Non-perforating  injury  to  right  internal  carotid  artery. 
Patient  was  admitted  into  No.  20  General  Hospital  under  the  care  of 
Captain    Burrows  in  1916.       He    was  wounded  on   July  27  by  a  small 

10 


146     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

piece  of  shell-casing  from  a  shell  that  burst  close  beside  him.  He  fell  at 
once,  and  has  no  definite  memory  of  what  immediately  followed,  but  he 
was  probably  rendered  unconscious.  He  says  he  was  able  to  get  up  in 
about  ten  minutes"  time,  but  was  unable  to  w  alk  in  consequence  of  weakness 
of  his  left  lower  extremity  ;  the  left  upjier  he  only  discovered  to  be  weak 
after  he  reached  the  hospital  on  a  stretcher.  The  wound  consisted  in  a 
gaping  slit  about  an  inch  long  just  anterior  to  the  right  tragus.  -Y-ray 
examination  showed  the  piece  of  shell  behind  the  pharynx  on  the  front  of 
the  body  of  the  second  cervical  vertebra,  where  it  was  also  palpable.  The 
condition  on  Aug.  4  was  as  follows  : — 

"  The  man  is  quite  intelligent,  but  has  slight  difficulty  in  articulation 
due  to  facial  paresis.  The  right  temporal  artery  cannot  be  felt  to  pulsate. 
The  pupils  are  equal,  and  react  normally.  There  is  incomplete  right  peri- 
pheral facial  palsy,  and  slight  but  definite  paresis  of  the  upper  neurone  type 
upon  the  left  side.  The  tongue  is  protruded  to  the  left,  and  the  left  side  lies 
higher  in  the  mouth.  Motor  system  : — The  right  upper  extremity  is  normal, 
the  left  flaccid  and  toneless.  There  is  slight  power  of  flexion  in  the  fingers, 
but  no  power  of  extension,  nor  of  adduction  or  abduction.  Flexion  and 
extension  of  the  wrist  are  very  feeble,  and  limited  in  range.  The  shoulder 
and  elbow  movements  are  stronger.  In  forced  inspiration  the  right  side  of 
the  chest  moves  better  than  the  left.  The  right  lower  extremity  is  normal  ; 
the  tone  of  the  muscles  of  the  left  is  fair,  and  all  movements  are  possible, 
especially  the  more  distal,  but  they  are  weaker  than  those  of  the  right  limb. 
Reflexes  : — Arm -jerks  :  R.  normal  ;  L.  feeble.  Knee-jerks  :  Equal  and 
brisk.  Ankle-jerks  :  Equal  and  brisk.  Abdominal  :  R.  brisk  ;  L.  almost 
absent.  Plantar  :  R.  flexor  ;  L.  extensor.  Sensation  : — Considerable 
alteration  in  the  sense  of  touch,  but  no  complete  loss,  is  present  in  the  left 
side  of  the  head  and  trunk  and  the  left  upper  extremity.  Contact  produces 
tingling.  Localization,  sense  of  form,  and  position  are  all  very  defective  in 
the  left  upper  extremity." 

Of  the  above  five  cases  four  are  of  the  class  in  which  no  perforat- 
ing injury  was  considered  to  be  present,  but  they  offered  no  differences 
in  history  or  character  of  the  sym^Dtoms  from  those  in  which  either 
an  arterial  bruit,  an  aneurysmal  sac,  or  the  occurrence  of  secondary 
hsemorrhage  indicated  the  presence  of  an  opening  in  the  wall  of  the 
vessel — that  is,  conditions  still  more  favoiu-able  for  the  formation  of 
a  thrombus. 

This  series  of  cases  may  be  suiDplcmented  by  the  recital  of  two 
in  which  cerebral  symptoms  developed  after  operations,  an  embolism 
being  responsible  in  one  case,  and  a  progressive  thrombosis  in  the 
other. 

Case  25. — Arterial  aneurysm  of  right  common  carotid.  Lig-ature  below^ 
the  omohyoid.     Cerebral  embolism. 

A  man  was  admitted  on  the  fourth  day  after  receiving  a  wound  at  the 
level  of  the  upper  margin  of  the  right  ala  of  the  thyroid  cartilage.  The 
missile  was  retained.  The  blood  s])urted  'as  from  a  tap"  at  first,  and  the 
patient  fainted,  but  a  pad  was  applied  and  ha;morrhage  ceased  permanently. 

On  admission,  a  pulsating  tumour  2i  in.  by  3  in.  was  present  at 
about  the  level  of  the  top  of  the  thyroid  cartilage  ;     there    was  a   little 


VESSELS    OF    THE    NECK  ]47 

general  oedema  of  the  side  of  the  neck,  and  ecchymosis  aloiij^  liie  lino 
of  the  vascular  cleft,  extending  down  over  the  front  of  the  first  piece  of  the 
sternum.  A  loud  simple  systolic  bruit  was  audible  on  auscultation.  The 
patient  improved  when  kept  at  rest,  the  pulse  averaging  88,  and  the  oedema 
of  the  neck  decreased. 

On  the  ninth  day,  some  evidence  of  extension  along  the  line  of  the  vas- 
cular cleft  suggested  the  wisdom  of  ligaturing  the  artery,  and  this  was  done 
by  Captain  Kelly.  The  ligature  was  placed  below  the  omohyoid,  and  pulsa- 
tion in  the  aneurysm  ceased.  The  patient  progressed  well  for  four  days, 
the  aneurysm  solidified,  and  feeble  pulsation  could  be  detected  in  the  distal 
portion  of  the  carotid. 

On  the  fifth  day  after  the  operation,  the  patient,  who  had  been  bright 
and  well  all  the  afternoon,  suddenly  became  drowsy  and  hemiplegic.  On 
the  twentieth  day  he  was  transferred  to  England,  in  fair  bodily  and  mental 
condition,  but  still  completely  hemiplegic. 

Little  subsequent  improvement  took  place. 

Case  26. — Arterio- venous  aneurysm.  Suture  of  vessels.  Progressive 
thrombosis. 

The  patient  was  suffering  with  an  arterio-venous  aneurysm  of  two  years' 
standing.  The  sac  was  large,  more  than  an  inch  and  a  half  in  diameter,  and 
projected  forwards  in  the  anterior  triangle  of  the  neck.  It  was  showing  signs 
of  enlargement,  and  caused  some  inconvenience  from  the  buzzing  sound 
at  night. 

Exploration  disclosed  a  thick-walled  sac  springing  from  the  right  common 
carotid  artery  just  below  the  bifurcation.  The  defect  in  the  vessel  wall  was 
three-quarters  of  an  inch  long,  and  involved  about  half  the  circumference  of 
the  lumen.  The  artery  was  reconstructed  by  utilizing  a  flap  cut  from  the 
wall  of  the  sac,  and  the  opening  in  the  vein  closed  by  a  vertical  line  of  suture. 

The  operation  occupied  two  hours,  and  upon  the  same  evening  the 
temperature  rose  to  108°.  The  next  morning  the  temperature  had  fallen  to 
normal,  and  the  pulse-rate  was  96.  Twenty-four  hours  after  the  operation 
the  patient  had  hardly  recovered  consciousness  ;  he  was  drowsy,  and 
although  he  appeared  to  recognize  persons,  he  did  not  speak.     (G.  H.  M.) 

The  patient  had  been  very  restless  during  the  night,  and  two  injections 
of  J  gr.  of  morphia  had  been  administered.  During  the  day  improvement 
took  place,  and  all  four  limbs  could  be  moved.  Urine  was  once  passed 
involuntarily  into  the  bed. 

On  the  third  day  the  patient  was  still  very  drowsy  ;  he  answered 
questions  sensibly,  but  appeared  rapidly  to  tire  mentally.  The  aspect  was 
decidedly  cerebral,  the  face  thin,  pinched,  and  slightly  cyanotic.  He  com- 
])lained  of  headache  on  the  right  side,  and  of  some  difficulty  in  swallowing. 
The  pupils  were  equal  and  reacted  norinally,  and  no  weakness  of  the  limbs 
was  detected.     No  pulsation  could  be  detected  at  the  site  of  the  suture. 

On  the  fourth  day  there  was  left  facial  weakness,  and  nximbness  and 
some  loss  of  power  in  the  left  hand,  with  loss  of  sense  of  position,  and 
inability  to  discover  the  nature  of  an  object  placed  in  the  hand.  The  lower 
limb  was  normal.  The  difficulty  in  swallowing  had  lessened.  The  patient 
was  very  slow  in  emptying  his  bladder,  although  he  felt  the  desire  to 
micturate.     Cerebration  remained  slow,  and  efforts  to  talk  rapidly  tired  him. 

From  this  date  steady  improvement  took  place,  and  at  the  end  of  ten 
days  the  facial  weakness  was  slight  and  the  power  of  the  arm  had  been 
practically  regained.  The  carotids  were  pulsating  freely  at  tliis  date,  sug- 
gesting that  the  primary  thrombus  had  now  been  absorbed. 


148         GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 


Table    /.—TRAUMATIC     ANEURYSMS     ACCOMPANIEI 


Position  op  wound 

AND 

Nature  of  missile 


Local  Pulsation, 
Thrill,    or  Murmur 


Tejiporal  Pulses  : 

I    indicating  THROJIBOS 

OK  Embolism 


19, 


.15 


18.1.6 


6.7.16 


10.5.16 


Small  incised  wound  over  left 
sternomastoid  at  level  of  angle 
of  jaw.     Fragment  of  shell 


Large  wound  posterior  border  of 
sternomastoid.     Shell 


Entry  3  in.   directly  below  left 
external  auditorv  meatus.  Shell 


Oval  slit  1  in.  behind  anterior 
margin  of  right  sternomastoid, 
at  level  of  thvroid  cartilage 


Arterio-venous  aneu- 
rysm of  internal 
carotid 


Equal. 

?  Embolism 


Arterio-venous  hjema- 
toma,  common  caro- 
tid 


Arterial     haematoma, 
common  carotid 


Arterial  aneurysm  of 
common  carotid 


Arterio-venous  aneu- 
rysm of  common 
carotid 


Left  temporal  pui 

absent. 
?  Thrombosis 

Right         tempo  I 

pulse   absent. 
?  Thrombosis 


Equal. 

?  Embolism 


VESSELS    OF    THE    NECK 


149 


BY     CEREBRAL     COMPLICATIONS. 


DATE  OP 
ONSET 


Signs  op  Injury  to 
Syjipathetic 


Signs  op  Cerebral  Disturbance 


progress  and 
Complications 


Early 


Right  pupil  dilated, 
left  palpebral  fissure 
narrow 


6th  day 


None 


Left  pupil  contracted 


None 


None 


Slight  weakness  right  face,  and 
tongue  to  right  side.  Motor 
system  : — Upper  extremity  :  L. 
normal  ;  R.  no  power  of  move- 
ment. Lower  extremity  :  L. 
normal  ;  R.  some  tone,  won't 
move  on  order,  withdrawal  on 
prickingsole.  Sensory  system  : — 
Position  :  Much  loss  right  hand 
and  arm.  No  further  tests  pos- 
sible. Reflexes: — Arm-jerk  :-|-. 
Knee-jerk:  +  +;  R.  >  L. 
Ankle-jerk  :  +.  Abd.  :  R.  0  ; 
L.  +.  Plantar  :  R.  extensor  ; 
L.  flexor 

Complete  left  hemiplegia 


Difficulty     in    articulation     and 
swallowing 


Tongue  protruded  to  right.  Right 
facial  paresis.  Right  upper  ex- 
ti'emity  powerless.  Some  tone 
in  right  lower  extremity,  but 
could  not  move  it  to  order 


No  improvement 


Anaerobic  infection. 
Secondary  haemor- 
rhage.    Death 


Improved  after  liga- 
ture of  the  carotid 


The  common  carotid 
was  tied  proxim- 
ally.  Improvement 
followed  in  condi- 
tion of  arm,  but 
none  in  face  and 
tongue 


150         GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 


Table     //.—POST-OPERATIVE     CASES 


No. 


Date  op 
Wound 


Position  and   stature  op  AVound 


Local  Pulsation, 
thrill,  or  murmur 


1.2.16 


12.1.K 


23.7.16 


16.8.16 


16.9.16 


1.9.16 


15.. 5. 16 


Wound  at  upper  border  of  thy- 
roid cartilage  ;  missile  retained 
left  side  4th  intervertebral  disc 

Through-and-through  track  from 
anterior  border  right  sterno- 
mastoid  to  left  sternoclavicular 
joint 


Wound    in     posterior    triangle 
retained  missile 


Missile    entered    through  mouth 
and  was  retained 


Fractured  jaw 


Fractured  jaw 


Small  through-and-through  track 
at  level  of  upper  border  of  thy- 
roid cartilage 


Arterio-venous  aneu- 
rysm, common  caro- 
tid 

Arterio-venous  aneu- 
rysm on  one  side, 
arterial  on  other 
side,  of  neck,  com- 
mon carotid 

Arterio-venous  hsema- 
toma,  common  caro- 
tid 

Arterio-venous  aneu- 
rysm, common  caro- 
tid 


Arterial     haematoma, 
common  carotid 


Arterial  hrematoma 


Nature    op 
Operation 


Ligature   of  caro- 
tid in  4th  week 


Insertion  o1 
Tu flier  tube  or 
37th  dav 


Ligature  of  arter;y 
on  4th  day,  foi 
extension 

Ligature  on  16tl 
day  for  second 
arv  ha?morrhage 


Ligature  on  4th 
day  for  second 
ary  haemorrhage 

Ligature  of  ex- 
ternal carotid 
8th  day.  Liga- 
ture common 
carotid  9th  day 
for  .secondary 
haemorrhage 

Ligature  of  in- 
ternal carotid' 
for  secondary 
haemorrhage 


Ligature  of  com- 
mon carotid  onj 
11th  dav 


VESSELS    OF    THE    NECK 


151 


ACCOMPANIED     BY     CEREBRAL     COMPLICATIONS. 


Date  op 
)nset  after 
Operation 

Signs  o^  Injury  to 
sympathetic 

SIGNS  OF  Cerebral  Disturbance 

Progress   and 
Complications 

1  day 

— 

Right  hemiplegia  and  aphasia 

?  Embolic.     Death 

id  day 

— 

Temporary  loss  of  power  in  left 
arm.     Headache.     Vomiting 

Died  from  general  tox- 
aemia a  few  days  later. 
?  Embolic 

mediate 

— 

Complete  hemiplegia 

Died  the  night  of 
operation.  No  naked- 
eye  changes  in  brain 

mediate 

None  ;     but  sym- 
pathetic     irrita- 
tion     (sweating) 
on      same      side 
after    operation 

Complete  hemiplegia.    Dull  men- 
tally.    Limbs  flaccid 

Much  improved  at  end 
of  three  weeks.  Some 
movement  of  leg 

ted  3rd  day 

None 

Complete  hemiplegia  with  aphasia 

At  end  of  10th  day 
aphasia  gone  and  limb 
improving 

mediate 

None 

Complete  hemiplegia 

No  improvement  in 
three  months 

ibolism 
date 

None 

Aphasia.     Laryngeal  paralysis 

Death.  Clot  in  middle 
cerebral  artery,  soft- 
ening, and  haemor- 
rhage into  internal 
capsule 

iibolism 
:h  day 

None 

Complete  left  hemiplegia 

Little  improvement 

152         GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 


Table    ///.—CASES     OF     MINOR     INJURY 


No. 


Date  op 
Injury 


Position  op  Wound 

AND 

Nature  op  missile 


16.5.15 


3  !   12.12.15 


18.12.15 


21.5.16 


4.1.16 


3.1.16 


Wound  back  of  side  of  neck 
over  trapezius  opposite  sixth 
cervical  vertebra.  Missile  re- 
tained, or  escaped  by  mouth 

Entry  right  side  of  neck  middle 
of  anterior  border  of  sterno- 
mastoid.  Retained  fragment  of 
shell.     (Left  scalp  wound.) 

Entry  anterior  border  of  sterno- 
mastoid  right  side  1  in.  above 
sternum.  Retained  over  spines 
of  6th  and  7th  dorsal  vertebrse. 
Bullet 

Entry  and  exit  small,  over  left 
carotid.  Left  scalp  wound  ; 
trephined  ;    nil   found.     Bomb 


Small  slit  near  anterior  border  of 
sternomastoid  1  in.  below  angle 
of  jaw.    No  exit  wound.    Shell 


Entry  wound  middle  of  right 
sternomastoid  on  level  with  thy- 
roid. Exit  wound  in  anterior 
margin  left  trapezius  1  in.  lower 
level 


LOCAL  Pulsation, 
Thrill,  or  Murmur 


Temporal   Pulses 

INDICATING  THROJIBO 

OR  Ejibglism 


Small  circular  area  of 
induration.  No  ab- 
normal pulsation. 
No  murmur.  Pulse 
120  at  first,  fell  to  84 

No  carotid  pulsation. 
No  murmur.  Pulse 
142 


No  swelling  or  pulsa- 
tion.    No  murmur 


No  pulsation  or  thrill. 
No  murmur 


No  pulsation  or  thrill. 
No  murmur 


Soft     systolic     bruit. 
No  conduction 


Entry  centre  of  anterior  border      No  pulsation  or  thrill, 
of  left  sternomastoid.   Exit  just  ,     No  murmur 
in  front  of  angle  of  jaw,  right 
side.     Bullet 


Entry  wound  just  in  posterior 
margin  of  middle  of  left  sterno- 
mastoid.    Shell 


No  pulsation  or  thrill. 
No  murmur 


?  Left  >  right 


Absent  on  left  s 


?  Diminished     c 
left  side 


Equal    on   the  t 
sides 


Equal    on  the  f 
sides 


Equal    on  the  t' 
sides 


Left  tem))oralpu 
absent 


Equal   on    the  t^ 
sides 


VESSELS    OF    THE   NECK 


153 


XOMPANIED     BY     CEREBRAL     COMPLICATIONS. 


Signs  of  Injury  to 
Sympathetic 


Signs  of  Cerebral  disturbance 


Progress   and 
Complications 


No  evidence 


Pupils,  right  >  left. 
?  Sweating  more 
left  side  of  face 


Pupils,  right  >  left. 
Slight  ptosis 


Left  pupil  >  right 


No  evidence 


No  evidence 


Pupils,  left > right 


Pupils,  right  >left. 
Left  palpebral 
fissure  narrow. 
Left  side  of  face 
more  flushed 


LTnconscious  at  first.  Mental 
condition  improved.  Speech  not 
bad.  Difficulty  in  reading  and 
writing.  Motor  system  : — Right 
hemiplegia 

Right  face  very  weak.  Motor 
system  : — Upper  and  lower  ex- 
tremities :  L.  normal  :  R.  no 
power  of  movement  ;  slight 
rigidity  of  right  limbs.  Sensory 
system  : — Reacts  to  pin-prick 
on  both  sides.  Reflexes  : — 
Arm-jerk  :  L.  -|-  ;  R.  0.  Knee- 
jerk  :  R.>L.  Ankle-jerk:  R. > 
L.  Abd.  :  L.  -f  ;  R.  0.  Plan- 
tar :   L.  flexor  ;   R.  extensor 

Motor  aphasia.  Weakness  of  right 
face.  Tongue  deviates  to  left. 
Motor  system : — Weakness  right 
upper  extremity.  Some  rigidity 
at  elbow 

No  mental  change.  Motor  sys- 
tem : — Upper  and  lower  ex- 
tremities :  L.  no  power  of 
movement  :    R.  normal. 


Dull  and  stupid.  Motor  sys- 
tem : — Upper  extremity  :  L.  no 
power  of  movement  ;  R.  bra- 
chial monoplegia.  Paraplegia 
paralysis  of  bladder  and  rectum 


Died 


Aphasia  and   paralysis 
improved 


Rigidity  in  left  arm 
after  three  days'  inter- 
val, which  increased, 
with  a  great  deal  of 
pain 

No  improvement  took 
place.  Transferred  to 
England 


Aphasic.  Quite  conscious.  Motor  Improved     after     iiga- 

system  : — Upper  and  lower  ex-  \     ture    of    carotid     for 

tremities  :     L.  normal;     R.  no  I     secondary    haemor- 

power  of  movement  rhage 


Mental  condition  normal.  Motor 
system  : — Upper  extremity  :  L. 
normal  ;  R.  forearm  paralyzed, 
and  biceps  and  triceps  slightly. 
Lower  extremity  :  L.  and  R. 
normal 

Dull  and  drowsy.  Motor  aphasia. 
Right  side  of  face  weak.  Motor 
system  : — Upper  extremity  :  L. 
normal;  R.  flaccid,  distal  move- 
ment very  weak.  Lower  extrem- 
ity :    L.  and  R.  normal 


"Went  home  nearlv  well 


Went  home  consider- 
ably improved.  Right 
arm  better.  Speech 
better 


Coiitiniied  on  next  page. 


15  i        GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

Table     III CASES     OF     MINOR     INJURY 


Date  op 
Injury 


Position  op  Wound 

AND 

NATURE  OP  Missile 


Local  Pulsation, 
Theill,  ou  Murmur 


TEMPORAL  Pulses  ; 

INDICATINM  THROMBOI 

OR  Embolism 


24.1.16 


10      27.7.16 


11   i  25.9.16 


12 


6.4.17 


1.3      20.2.17 


14 


15 


30.1.17 


13.7.16 


Entry  |  in.  to  rioht  of  4th  cervi- 
cal spine.  Exit  1  in.  outside 
right  angle  of  mouth.     Bullet 


Irregular  gaping  wound  about 
1  in.  long  immediately  in  front 
of  tragus.      Shell  (retained) 


Entry   left   side    of   chin, 
posterior  triangle 


Exit 


Small  entry  wound  over  thyroid 
cartilage  in  mid-line 

Small  entry  wound  at  left  angle 
of  mandible.  Exit  below  right 
mastoid  process 

Centre  of  right  cheek.  Right 
pinna.    Right  mastoid  process 

Entry  at  junction  of  right  ala 
nasi  with  cheek 


No    pulsation,    thrill, 
or  murmur 


No 


pulsation,    thrill, 
or  murmur 


Swelling  left   side   of 
neck.     No  pulsation 


or  murmur 


No     tumour,     pulsa- 
tion, or  bruit 

No  tumour  or  pulsa- 
tion 


No  tumour  or  pulsa- 
tion 

No  tumour  or  pulsa- 
tion 


Equal 
sides 


on   the  t' 


Right      tempo) 
pulse  absent 


Equal  on  the  t^ 
sides 


Equal   on  the  t\ 
sides 


VESSELS    OF    THE    NECK 
;OMPANIED     BY     CEREBRAL     COMPLICATIONS — continued. 


15.5 


DATE  OP 
ONSET 

Signs  of  Injury  to 
Sympathetic 

Signs  op  Cerebral  Disturkancb 

Progress   and 

COMl'LICATIONSj 

I,eft  pupil  >  right. 

Left  face  paralyzed  (supranuclear). 

Right  face  more 

Motor  system  : — Upper  extrem- 

flushed 

ity  :      L.   rigid   and   completely 
paralyzed  ;     R.  normal.    Lower 
extremity  :  L.  rigid,  slight  vol- 
untary movement  at  hip  only  ; 
R.  normal.     Sensory  system  : — 
Entire  loss  left  side.  Reflexes  :• — ■ 
All  increased  left  side.    Plantar 
reflex  extensor  on  left  side 

No  evidence 

Incomplete  peripheral  facial  palsy 
right,  and  slight  upper  neurone 
paresis  left  side.  Motorsystem: — 
Upper    extremity  :      L.    flaccid 
and  toneless,  some  power  ;     R. 
normal.     Lower  extremity  :    L. 
movements   weaker  than   right 
side  ;      R.    normal.      Sensation 
diminished  on  left  side.  Reflexes 
diminished.     Plantar  reflex  ex- 
tensor on  left  side 

.16. 

Pupils   equal    and 

Right     hemiplegia.          Aphasia. 

Slight  improvement  on 

owsy. 

contracted 

Facial  paralysis.     Incontinence 

transfer.        Not     con- 

.16. 

of  urine  and  fseces 

tinued. 

:cited, 

17.10.16.      Slight  right 

niplegic. 

facial  paralysis.  Right 

1  aphasic 

' 

hemiplegia.     Very 
slight    movement    of 
right  leg.     Knee-jerks 
+  +.      Ankle-clonus. 
Thick  speech.  langual 
paralysis.         Muddles 
words.     Incontinence 
improved.       Right 
arm  total  paralysis. 
1.10.17.      Facial    para- 
lysis slight.     Can  flex 
right  arm  ;  no  exten- 
sor   power.       Fingers 
contracted ,    but     can 
be  straightened.     Can 
flex  thigh,  knee,  and 
ankle.     Foot  stiff  and 
inverted.     Knee-  and 
ankle-clonus. 

iiediate  (?) 

Pupils    equal  and 

Right  hemiplegia 

Died    5th    day     (Case 

reacted 

16). 

day 

— 

Complete  left  hemiplegia 

Died  4th  dav  {Case 
17). 

wsy 



Coma.     Signs  of  compression 

Died     2nd    dav    {Case 

mediately 

18). 

or  3rd  day 

■ — 

Right  hemiplegia.     Coma 

Died  3rd  dav  {Case 
19). 

156      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

Mode  of  Onset,  Variations  in  Degree  of  Severity,  and  Prognosis 
in  Cases  attended  by  Cerebral  Complications. — The  mode  of  onset  after 
ligature  of  the  common  carotid  artery  is  fairly  constant.  As  a  rule 
the  cerebral  symptoms  are  either  immediate,  or  noticed  in  the  course 
of  a  few  hours.  When,  after  the  application  of  a  proximal  ligature, 
the  distal  segment  of  the  ^-essel  is  left  in  communication  with  the  sac 
of  an  aneurysm,  the  detachment  of  an  embolus  may  take  ])lace  after 
a  few  days,  or  even  at  a  more  remote  period.  Two  such  cases  are 
recorded  in  Table  II   (Nos.  7  and  8). 

When  the  cerebral  symptoms  follow  thrombosis  of  the  artery,  it 
is  far  more  difficult  to  say  when  they  are  likely  to  develop.  In  some 
of  the  cases  recorded  above  they  Avere  immediate,  and  the  course  of 
events  is  identical  with  that  seen  after  occlusion  of  the  vessel  by  liga- 
ture. In  other  instances  the  symptoms  were  delayed,  and  then  it  is 
reasonable  to  assume  that  the  thrombosis  was  of  the  extending  variety. 
This  conclusion,  however,  is  open  to  much  doubt,  since  an  extensive 
thrombus  may  form  without  an}^  apparent  ill  result  ;  thus,  the  internal 
carotid  artery  in  the  neck  has  been  seen  to  be  blocked  throughout 
during  the  course  of  an  operation  for  ligature  of  the  common  carotid, 
and  yet  no  signs  existed  at  the  time  or  developed  afterwards.  When 
the  symptoms  first  become  apparent  at  a  later  date,  it  seems  reason- 
able to  assume  the  lodgement  of  an  embolus  ;  but  here  again  the 
mere  question  of  date  helps  us  little,  and  a  certain  diagnosis  is  more 
likely  to  be  made  when  the  paralysis  is  incomplete,  by  a  careful  con- 
sideration of  the  focal  signs  present  as  a  means  of  locating  the  position 
of  the  embolus. 

The  general  lines  upon  which  a  diagnosis  is  to  be  based  have 
already  been  mentioned  ;  it  remains  to  impress  the  experience  that  it 
is  easy  to  mistake  signs  due  to  a  purely  vascular  disturbance  for  those 
of  compression  resulting  from  injury  to  the  brain,  or  intracranial 
ha-morrhage.  Two  of  the  cases  related  above  illustrate  this  point. 
I  saw  a  third  in  which  a  trephine  opening  had  been  made  ;  and  in 
a  fourth  (No.  4,  Table  III),  bilateral  symptoms,  in  conjunction  with 
the  presence  of  a  scalp  wound  on  the  opposite  side  of  the  head, 
suggested  a  combination  of  contusion  of  brain  and  possibly  hemor- 
rhage on  one  side  with  Avascular  disturbance  on  the  other.  The 
existence  of  an  optic  disc  in  the  early  stage  of  papillitis,  so  commonly 
seen  in  conjunction  with  the  oedema  of  the  brain  occurring  in  the 
early  stage  of  cerebral  injvu'ies,  might  ]:)rove  a  useful  diagnostic  point. 

Prognosis. — Reference  to  the  tables  gives  some  idea  of  the 
gravity  of  cerebral  complications  in  vascular  disturbance,  but  it  must 
be  remembered  that  the  series  of  cases  here  recorded  are  all  of  a  severe 
type.  All  except  the  first  four  (which  terminated  fatally)  were 
observed  in  general  hospitals  on  the  lines  of  commuiiication — that  is. 


VESSELS    OF    THE    NECK  157 

some  days  after  the  reception  of  the  injury.  This  fact  tends  to  show 
that,  while  on  the  one  hand  fatah'ties  may  be  even  more  numerous 
than  was  the  case  here,  yet  time  enongh  had  elapsed  for  j)atients 
with  evanescent  symptoms  to  have  got  over  their  troubles  without 
the  real  nature  of  the  signs  having  been  discovered.  We  are  well 
aware  that  the  pareses  and  even  paralyses  which  may  follow  ligatnre 
of  the  common  carotid  artery  are  sometimes  very  transient,  some- 
times persistent,  sometimes  followed  by  a  fatal  issue  ;  and  there  can 
be  little  doubt  that  the  similar  conditions  due  to  vascular  disturbance 
from  thrombosis  or  embolism  may  follow  the  same  course.  We  also 
know  that  thrombosis  of  the  carotids  may  give  rise  to  no  symptoms 
whatever  ;  further,  that  when  paralysis  does  occur,  the  patients  are 
either  unconscious  of  it,  or  unwilling  to  recognize  it.  Hence  we  are 
justified  in  the  assumption  that  the  proportion  of  patients  in  whom 
the  symptoms  are  transient  or  slight  is  far  greater  than  the  series 
under  consideration  would  suggest. 

The  material  furnished  above  may  be  shortly  summarized  as 
follows  : — 

Amongst  14  cases  in  which  the  common  carotid  artery  was 
ligatured  for  the  treatment  of  secondary  haemorrhage,  hemiplegia 
developed  in  .3  (21-4  per  cent)  ;  in  one  of  these  death  occiuTed  within 
twenty-four  hoiu's,  in  a  second  the  hemiplegia  and  aphasia  improved, 
and  in  a  third  it  w'as  persistent. 

In  13  cases  in  which  the  operation  was  undertaken  for  the 
early  treatment  of  either  arterial  or  arterio-venous  ha^matomata, 
hemiplegia  developed  in  5  instances  (38-4  per  cent).  In  one  patient 
the  paresis  was  transient ;  in  one  partial  recovery  ensued  ;  in  one  the 
paralysis  persisted  with  little  improvement ;  and  in  two  death  resulted. 
One  death  took  place  within  twenty-four  hours  ;  the  second  was  not 
directly  the  result  of  the  arterial  injury  or  of  its  treatment,  the  patient 
dying  of  general  infection  from  multiple  wounds,  and  the  paralysis 
was  transient  and  of  the  upper  extremity  only. 

If  these  two  short  series  be  combined,  we  have  a  total  of  27  cases 
of  ligature  of  the  common  carotid,  in  8  of  which  (29-6  per  cent) 
cerebral  complications  ensued,  and  3  of  the  patients  succumbed, 
two  as  a  direct  consequence  of  the  operation  ;  only  one  of  the  eight 
patients  recovered  his  normal  state. 

The  prognosis  in  the  15  cases  of  cerebral  complications  conse- 
quent on  minor  injuries  to  the  vessels,  followed  either  hj  thrombosis, 
or  thrombosis  and  embolism,  is  still  more  gra'sx ;  but  in  this 
instance  the  fact  already  mentioned  must  receive  full  recognition, 
i.e.,  that  we  are  in  complete  ignorance  of  the  number  of  such 
injuries  in  which  traumatic  thrombosis  has  led  to  no  evil  effect 
whatever,  and  perhaps  of  the  still  lai'ger  number  in  which  transient 


158       GUNSHOT    IXJUIUES    TO    THE    BLOOD-VESSELS 

phenomena  have  been  present,  the  real  significance  of  ■\vliieli  A\as 
not  appreciated. 

Amongst  the  15  cases,  death  occurred  in  5  (33-3  per  cent) 
during  the  first  four  days.  Only  one  instance  of  transient  paresis  and 
complete  recovery  was  observed.  In  the  remaining  9  jjatients, 
although  improvement  occin-red  in  5,  all  were  discharged  from  the 
army  as  permanently  imfit,  and  probably  none  are  excv  likely  to  be 
able  to  follow  any  active  work. 

One  remarkable  observation  was  made  in  two  of  the  cases 
under  consideration — ligature  of  the  common  carotid  artery  being 
a]iparently  followed  by  a  distinct  imjirovcment  in  the  symptoms.  It 
is  difficult  to  explain  this  sequence  except  upon  the  theory  that  com- 
plete obstruction  of  the  partially  occluded  artery  led  to  a  greater 
degree  of  compensatory  dilatation  in  the  remaining  vessels. 

DEVELOPMENT  OF  TRAUMATIC  ANEURYSM. 

Arterial  Hsematoma  and  False  Traumatic  Aneurysm. — Amongst 
58  cases  of  aneurysm,  10  were  purely  arterial  in  origin  and  nature,  the 
remaining  48  being  of  the  arterio-venous  variety.  This  disparity  in 
the  case  of  the  carotid  vessels  is  to  be  explained  in  more  than  one 
way.  First,  the  cases  from  which  the  above  numbers  were  drawn 
Avere  all  observed  in  hospitals  either  upon  the  lines  of  communication 
or  at  the  base  at  home.  Thus,  all  cases  in  which  haemorrhage,  early 
increase  in  size  of  the  hfematoma,  or  the  attendant  woimds  of  the 
soft  parts,  were  extensive,  are  eliminated.  Secondl5^  the  long  and 
intimate  relation  of  the  carotids  and  the  internal  jugular  vein  affords 
particularly  favourable  conditions  for  contemporaneous  injiuy  to 
the  two  vessels.  Thirdly,  jDure  arterial  ha'matomata  are  more  liable 
to  continuous  increase  in  size,  or  secondary  extension,  than  those 
of  the  arterio-venous  variety,  because  the  safety-valve  afforded  by 
the  open  vein  is  absent.  The  powerful  suction  action  exercised  by 
the  induction  of  negative  intrathoracic  pressure  during  inspiration 
renders  this  latter  point  of  special  importance  in  carotid  arterio- 
venous aneiuysms. 

The  same  reasons  explain  the  fact  that  the  sacs  of  arterial 
aneurysms  commonly  reach  a  larger  definite  size  than  those  of  the 
arterio-venous  variety.  In  the  early  stages  those  in  the  upper  part 
of  the  coin-se  of  the  vessel  tend  to  be  the  larger  and  more  irregular 
in  outline,  as  the  firm  support  afforded  to  the  lower  part  by  the 
depressor  muscles  of  the  hyoid  bone  and  the  stcrnomastoid  is  wanting. 

The  artery  itself  tends  to  be  displaced  in  the  direction  of  least 
resistance,  that  is,  towards  the  mid-line  or  forwards,  but  in  some  cases 
the  aspect  on  which  the  vessel  is  wounded  may  determine  both  the 


VESSELS    OF    THE    NECK 


159 


position  of  the  sac  and  the  direction  in  which  the  vessel  is  displaced. 
In  others,  the  position  of  the  sac  is  determined  by  that  of  the  track 
made  by  the  missile,  and  it  may  be  situated  in  the  actual  substance 
of  a  muscle  such  as  the  sternomastoid  or  those  of  the  prevertebral 
region. 

A  fully-developed  sac  assumes  a  more  or  less  rounded  outline  as 
a  rule.  Spontaneous  consolidation  is  possible  :  I  have  seen  it  occur 
in  the  stage  of  wounded  artery  with  a  minimal  hscmatoma,  but  never 


v'^ 


KA-'VE'^k 


Fig.  42. — Carotid  arterial  aneurysm.  The  sac  has  been  opened.  The  drawing  illus- 
trates the  part  taken  by  the  remaining  strand  of  the  wall  of  the  vessel  in  the  formation 
of  the  sac,  also  the  anterior  displacement  of  the  artery. 


when  a  sac  of  any  extent  had  formed.  The  general  tendency,  however, 
is  towards  decrease  in  size  during  the  early  months.  I  have  known 
one  arterial  aneurysm  to  rupture  as  the  result  of  violent  exertion  after 
four  years  of  quiescence  ;  and  in  another  case  the  sac  persisted  without 
any  great  increase  in  size  for  six  or  seven  years,  the  patient  eventually 
dying  when  under  an  anaesthetic  for  an  operation.  The  latter  was 
determined  upon  in  consequence  of  the  patient  developing  occasional 


iGo    arxsnoT  ixjiiues  to  the  blood-vessels 

fits,  wliicli  were  increasing  in  frequency,  and  which  it  was  snsjiected 
mioht  be  due  to  the  passage  of  small  emboli  from  the  sac  to  the  brain. 
The  systolic  bruit  accompanying  an  arterial  aneurysm  is  occa- 
sionally conducted  to  the  cardiac  apex  or  the  base  of  the  left  ventricle. 
I  have  seen  three  examples  of  this. 

Arterio-venous  Aneurysm.  —  .Vs  lias  been  already  mentioned,  this 
variety  is  comparati\eh^  common  in  the  neck.  The  sacs  are  not  as  a 
rule  of  large  size,  and  this  again  may  be  referred  to  the  safety-valve 
provided  to  the  hcTmatoma  by  the  open  vein.  They  may  be  situated 
between  the  artery  and  vein,  in  connection  with  one  of  the  arterial 
wounds  alone,  or  in  both  situations.  If  the  sac  is  interposed  between 
the  vessels,  it  is,  in  my  operative  experience,  of  small  size.  In  one 
instance  in  which  I  operated,  the  sac  was  situated  behind  the  vessels, 
extending  into  the  substance  of  the  prevertebral  muscles,  and  artery 
and  vein  communicated  with  it  by  separate  openings  on  their  posterior 
aspect.  In  another,  the  blood  streaming  from  a  lateral  wound  of  the 
common  carotid  passed  by  means  of  the  sac  into  the  ojDen  low^er  end 
of  the  internal  jugular  vein.  The  upper  end  of  the  vein  w^as  closed, 
and  the  fragment  of  shell  which  had  caused  the  injury  was  enclosed 
within  the  aneurysmal  sac. 

Great  dilatation  of  the  vein  is  a  constant  feature  ;  it  pulsates 
freely,  and  in  many  instances  forms  the  major  portion  of  any  tumour 
which  may  exist.  The  wall  of  the  vein  becomes  at  an  early  stage 
considerably  thickened  (see  Fig.  43).  I  have  never  seen  a  true  venous 
sac.  The  wall  of  an  arterial  sac  is  firmer  than  the  thickened  vein,  but 
the  sac  may  be  tucked  away  laterally  or  behind  the  vessels,  where 
it  is  difficult  to  feel. 

Visible  pulsation  of  the  veins  in  the  posterior  triangle  is  not  un- 
common, and  the  purring  thrill  is  usually  well  marked  and  extensive 
in  distribution.  It  is  well  to  bear  in  mind  that  thrill  palpable  in  the 
jugular  vein  by  no  means  always  indicates  a  wound  of  the  main  vein 
itself  ;  it  is  often  strongly  conducted  even  when  a  branch  of  moderate 
size  is  the  vessel  implicated. 

Signs  of  venous  obstruction  in  the  peripheral  veins  are  uncommon. 
I  have  never  seen  them. 

The  local  murmurs  in  the  neck  are  loud  and  widespread,  often  so 
strong  on  the  opposite  side  as  to  suggest  a  bilateral  lesion.  The  con- 
ducted murmur  on  the  sound  side  maj^  be  of  a  somewhat  different 
character,  the  systolic  element  being  softer  and  more  '  blowing  '  in 
type.  The  sounds  can  usually  be  heard  over  the  upper  part  of  the 
chest  and  the  whole  precordial  area,  but  the  heart  sounds  are  distinct 
from  the  adventitious  bruit.  In  a  small  proportion  of  all  cases,  how- 
ever, the  systolic  element  transforms  the  first  sound  into  a  bruit  at 
the  base,  or  even  at  the  cardiac  apex. 


VESSELS    OF    THE    NECK  101 

Many  of  the  patients  complain  of  the  '  buzzino- '  sound  in  the 
head  and  ears  ;  it  may  be  especially  troublesome  in  the  opposite  ear. 
If  this  be  an  early  symptom  it  tends  to  wear  off,  but  when  it  recurs 
upon  resumption  of  active  life  after  a  period  of  rest,  it  may  be  per- 
sistent. The  noise  is  increased  on  stooping,  and  in  patients  of  a 
nervous  temperament  it  may  be  a  serious  trouble,  particularly  when 
the  sufferers  are  at  rest  in  the  recumbent  position  in  bed. 

I  have  never  seen  a  case  of  carotid  arterio-venous  aneurysm  get 
well  spontaneously  if  left  untouched. 

Aneurysmal  Varix. — The  anatomical  conditions  are  particularly 
favourable  to  the  development  of  pure  arterio-venous  communications 
without  the  intervention  of  a  sac.  Fig.  27  illustrates  a  direct  varix 
of  immediate  formation.  Figs.  30,  44,  depict  two  instances  in  which 
an  intermediate  structure,  the  vagus,  is  traversed  by  the  channel  of 
communication  between  the  vessels.  It  is  difficult  to  forecast  what 
would  have  been  the  ultimate  condition  in  either  of  these  two  lesions, 
but  it  may  be  assumed  with  a  certain  degree  of  confidence  that  the 
injury  depicted  in  Fig.  44  would  have  ended  in  the  formation  of  an 
intermediate  sac,  the  remaining  fibres  of  the  vagus  being  incorporated 
in  the  wall. 

The  signs  and  symptoms  of  aneurysmal  varices  in  the  neck  so 
nearly  simulate  those  of  arterio-venous  aneurysms,  that,  in  the  absence 
of  a  large  sac,  it  is  difficult  to  distinguish  the  two  conditions  clinically. 
A  diagnosis  really  depends  upon  size,  and  definite  evidence  of  the 
presence  of  a  sac,  and,  as  we  have  seen,  the  latter  may  be  small. 

The  tendency  is  for  these  communications  to  contract,  and  in 
some  cases  there  is  no  doubt  they  close  spontaneously.  I  have  twice 
seen  the  latter  result,  but  in  each  instance  the  volume  of  blood  flowing 
through  the  carotid  had  previously  been  reduced  by  proximal  ligature 
of  the  artery  in  order  to  obtain  consolidation  of  an  aneurysmal  sac. 

GENERAL    PROGNOSIS     IN     CASES     OF     CAROTID     INJURIES. 

From  a  consideration  of  this  series  of  cases  it  must  be  assumed 
that  wounds  of  the  carotid  arteries  are  attended  by  a  very  large  pri- 
mary mortality.  This  is  shown  by  the  following  facts.  I  never  saw 
a  successful  case  of  actual  primary  ligature  of  the  vessel  in  the  hospitals 
on  the  lines  of  communication  or  at  the  base  during  a  period  of  four 
years  ;  and  although  four  cases  of  early  ligature  are  included,  in  three 
of  these  the  wound  of  the  vessel  was  only  discovered  during  operations 
for  the  removal  of  retained  foreign  bodies,  and  in  the  fourth  the  oper- 
ation was  undertaken  on  account  of  steady  increase  in  the  size  of  the 
haematoma.  In  only  one  of  the  whole  series  here  dealt  with  did  a 
large  wound  of  the  soft  parts  accompany  the  injury  to  the  arter^^  and 

ii 


162     GUNSHOT    IXJllUES    TO    THE    BLOOD-VESSELS 

no  case,  is  included  in  whicli  the  vessel  Avas  found  thrombosed  and 
lying  in  the  floor  of  a  wound  of  the  neck.  It  only  remains  to  repeat 
that  the  infrequency  of  wounds  of  the  lower  third  of  the  common 
carotid,  and  the  fact  that  operative  procedures  haAC  not  disclosed 
complete  severances  of  continuity  of  the  trunk,  also  point  to  the 
fatality  of  injuries  of  these  classes. 

The  mortality  in  this  whole  series  of  85  injuries  observed  on  the 
lines  of  communication  or  at  the  base,  amounts  to  13  (15-2  per  cent). 
Three  deaths  were  to  be  ascribed  to  concurrent  injuries  of  other  parts, 
three  resulted  from  secondary  haemorrhage,  one  occurred  during 
chloroform  anaesthesia,  and  six  were  consequent  on  cerebral  compli- 
cations. 

The  question  of  the  occiu'rence  of  cerebral  complications  in 
injuries  to  the  carotid  vessels,  and  the  results  of  operative  treatment, 
have  been  dealt  with  in  other  sections. 

The  surgeon  is  chiefly  concerned  with  the  complications  that 
follow  upon  operation,  and  in  this  respect  it  is  clear  that  the  danger 
is  only  great  when  the  operation  has  to  be  undertaken  as  an  lu'gent 
measure  immediately,  or  during  the  first  days  that  follow  the  reception 
of  the  injury.  In  remote  operations  the  danger  is  not  great ;  and 
although  the  numbers  supporting  the  opinion  are  small,  yet  it  may  be 
confidently  stated  that  the  dangers  in  any  case  are  diminished  by 
simidtaneous  occlusion  of  the  jugular  vein. 

Arterial  Aneurysm. — Of  the  10  arterial  aneurysms  contained 
in  the  series,  none  died.  In  3,  nerve  complications  were  present, 
the  injury  being  to  the  seventh  nerve  in  1,  to  the  recurrent  laryngeal 
or  vagus  in  1,  and  to  the  brachial  plexus  in  1.  Five  patients  were 
sent  home  without  operation,  and  in  1  of  these  spontaneous  cure  took 
place.  Five  cases  were  operated  upon,  the  indications  being  secondary 
haemorrhage  in  1  (internal  carotid),  extension  of  the  aneiu-ysm  diu'ing 
the  hfcmatoma  stage  in  3,  and  expediency  in  1.  In  2  cases  cerebral 
complications  followed  uj^on  operation  :  in  one,  a  transient  hemiplegia 
probably  dvie  to  anaemia  ;  in  the  second,  permanent  hemiplegia  due 
to  embolism.  The  operations  were  in  1  case  proximal  ligature,  fol- 
lowed by  embolism,  the  clot  probably  originating  in  the  sac  ;  in  1  case 
(internal  carotid)  proximal  ligature  and  plugging  of  the  sac  ;  in  2  cases 
proximal  and  distal  ligatm-es  were  applied  to  the  artery  ;  and  in  1  case 
both  artery  and  vein  Avere  ligatured.  Transient  hemiplegia  followed 
one  of  the  operations  in  which  the  artery  only  was  dealt  Avith. 

Arterio-venous  Aneurysm.  —  The  48  arterio-A'-enous  aneurysms 
and  varices  Averc  distributed  as  folloA\'s  :  common  carotid  38,  external 
carotid  6,  internal  carotid  4. 

Concurrent  nerAc  lesions  exercised  no  obA'ious  influence  on  the 
course  of  the  cases.     In  at  least  10,  signs  of  paratysis  of  the  cerA'ieal 


VESSELS    OF    THE    NECK  103 

sympathetic  were  present,  and  in  2,  signs  attributed  to  irritation.  In 
2,  serious  lesions  of  the  vagus,  one  on  the  right  and  one  on  the  left 
side,  were  discovered  at  operations,  but  no  signs  leading  to  detection 
of  the  injury  had  been  noticed.  There  may  well  have  been  many 
others  in  the  series.  Laryngeal  paralysis  due  to  concussion  was 
observed  in  several  cases  ;  in  5,  luiilateral  abductor  paralysis  indicated 
injury  either  to  the  recurrent  laryngeal  branch  or  the  trimk  of  the 
vagus. 

Cerebral  complications  occurred  in  6  of  the  cases.  In  6,  hemi- 
plegia was  the  direct  result  of  the  injury  to  the  artery  ;  in  1  it  followed 
anaerobic  infection  of  the  wound  of  the  neck ;  in  1  it  was  an 
immediate  consequence  of  ligature  of  the  common  carotid  artery,  and 
in  1  a  secondary  consequence  due  to  the  detachment  of  an  embolus  ; 
in  1  it  resulted  from  thrombosis. 

Death  occurred  in  9  instances  (18-7  per  cent).  In  6  of  these  it 
was  due  to  other  conditions  :  cerebral  injury  1,  anaerobic  infection 
of  wound  of  neck  1,  general  infection  1,  spinal  meningitis  2,  death 
under  chloroform  anaesthesia  1.  One  patient  died  from  secondary 
haemorrhage,  1  from  acute  cerebral  anaemia  following  ligatiu-e  of 
the  common  carotid,  and  1  from  cerebral  embolism  after  ligature  of 
the  carotid. 

Of  the  surviving  39  patients,  26  were  sent  home  to  England  in 
good  condition,  and  of  many  it  has  proved  impossible  to  follow  the 
further  covu'se. 

Fourteen  were  operated  upon,  the  indications  being  :  secondary 
haemorrhage  1,  extension  of  aneurysm  5,  expediency  2,  remote  opera- 
tions 6.  In  6  the  operation  consisted  in  ligature  of  artery  and  vein 
above  and  below  the  wounds  and  clearance  away  of  the  sac  :  4  of  the 
operations  were  successful,  and  2  patients  died,  both  from  cerebral 
complications  (anaemia  1,  embolism  1).  In  1  the  sac  was  left  untouched. 
In  7  cases,  all  of  the  remote  class,  the  wounds  in  the  vessels  were 
sutured  and  the  sac  removed  after  the  aneurysm  had  settled  down  ; 
all  these  cases  recovered,  and — as  far  as  could  be  judged  after 
observation  for  several  weeks — with  persistence  of  the  lumen  of 
the  vessels  ;  in  one,  temporary  cerebral  symptoms  followed,  due 
to  thrombosis. 

It  may  be  assumed  that  these  12  patients  resumed  ordinary  life. 
I  believe  the  same  may  be  said  about  the  patients  who  were  returned 
to  England  with  aneurysmal  varices,  as  these  cases  usually  suffer  little 
inconvenience.  Two  patients  upon  whom  I  operated  in  1900  have 
remained  well  since  ;  one  of  them  was  in  command  of  a  battalion 
and  was  thrice  wounded  in  the  jDresent  war. 

I  have  twice  watched  the  gradual  close  and  spontaneous  cure 
of  carotid  aneurysmal  varices. 


161     GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

TREATMENT     OF     INJURIES     TO     THE     CAROTID     ARTERIES. 

In  the  primary  treatment  of  these  injuries,  the  ordinary  rules 
g'uidin^-  tlie  sm'geon  in  other  parts  of  the  body  are  to  be  observed.  In 
A'iew,  howc^'er,  of  the  grave  consequences  ^vhich  may  ensue  in  the 
event  of  recurrent  or  early  secondary  haemorrhage  oecin-ring,  very 
special  care  must  be  taken  not  to  overlook  an  arterial  injury,  and  in 
the  case  of  a  ha-matoma  developing  when  the  apertures  of  entry  or 
exit  of  the  soft  parts  are  of  any  considerable  size,  temporary  cessation 
of  bleeding  should  not  be  regarded  as  sufficient  justification  for  taking 
up  an  expectant  attitude.  The  risks  are  particularly  great  should  any 
doubt  exist  as  to  the  practicability  of  maintaining  the  woimd  in  an 
aseptic  condition. 

When  the  wounds  of  the  soft  parts  are  of  the  minimal  type, 
whether  they  are  through-and-through  tracks  or  the  foreign  body  is 
retained,  if  haemorrhage  has  ceased,  an  expectant  attitude  is  preferable ; 
especially  if  a  considerable  amount  of  blood  has  been  lost,  if  sjauptoms 
of  shock  are  present,  or  if  the  conditions  luider  which  the  operation 
has  to  be  undertaken  are  not  entirely  satisfactory.  Under  any  of 
these  circumstances  the  risk  of  delay  in  active  intervention  is  far  less 
than  that  attendant  on  sudden  occlusion  of  the  carotid  vessels  at  a 
period  when  the  general  blood-pressure  is  probably  low. 

When  the  primary  stage  has  been  passed,  the  indications  for 
operative  intervention  may  be  siimmarized  as  follows  :  (1)  Secondary 
haemorrhage,  either  from  the  external  wound  or  from  the  mouth ; 
(2)  Extension  of  a  hamiatoma,  whether  arterial  or  arterio- venous  in 
nature  ;  (3)  The  development  of  pressiu'e  signs  such  as  dyspncea  or 
dysphagia  ;    (4)  For  the  cure  of  a  traimiatic  aneurysm. 

When  secondary  haemorrhage  forms  the  indication,  in  no  other 
part  of  the  body  is  it  so  important  to  make  sure  that  the  source  of 
the  haemorrhage  is  really  from  the  parent  trunk  ;  in  not  a  few  cases 
the  common  carotid  has  been  occluded  when  the  wound  was  really 
situated  in  the  external  carotid  or  one  of  its  branches,  and  in  some  of 
these  with  fell  results.  To  avoid  this  unsatisfactory  occurrence,  even 
if  the  ligature  has  to  be  applied  in  haste,  it  should  not  be  permanently 
knotted  luitil  further  investigation  has  shown  that  the  iDarent  vessel 
must  be  sacrificed.  When  branches  of  the  external  carotid  are  the 
obvious  soiu'ce  of  secondary  hamorrhage  from  the  neck,  as  in  cases 
of  fractured  jaw,  Captain  Biutows*  has  shown  that  when  it  is  not 
possible  to  secure  the  actual  bleeding  point,  proximal  ligature  of  the 
branches,  especially  of  the  lingual,  is  preferable  to  occluding  even  the 


British  Journal  of  Surgery,  1917,  vol.  v,  No.  17,  July,  p.  137. 


VESSELS    OF    THE    NECK  105 

external  carotid,  and  this  experience,  after  all,  coincides  with  that 
afforded  by  the  treatment  of  haemorrhage  in  other  parts  of  the  body. 

In  estimating  extension  of  a  ha;matoma  as  an  indication  ffjr 
intervention,  it  is  well  to  remember  that  variations  in  size  are  not 
nncommon,  and  may  be  observed  from  day  to  day  in  the  early 
stages.  These  variations  may  depend  on  changes  in  the  blood- 
pressure,  .  on  a  varying  amount  of  oedema,  or  on  unnecessary  move- 
ments on  the  part  of  the  patient,  and  are  not  always  to  be  too 
highly  estimated. 

Dyspnoea  or  dysphagia  is  generally  a  sign  not  to  be  disregarded, 
and  in  relation  to  the  former,  it  may  be  pointed  out  that  direct  treat- 
ment of  the  ha?matoma  at  once  relieves  it,  and  care  should  be  exercised 
that  a  preliminary  tracheotomy  is  not  unnecessarily  midertaken,  as  has 
sometimes  been  the  case. 

When  the  existence  of  a  well-localized  hsematoma  or  false 
aneurj^sm,  either  arterial  or  arterio-venous,  forms  the  indication,  the 
principal  question  which  arises  is  as  to  the  most  suitable  moment  for 
ntervention.  Spontaneous  consolidation  is  rare  in  arterial,  and  I  do 
not  believe  it  ever  occurs  in  arterio-venous  aneurysms.  The  presence 
of  the  condition  is  an  actual  bar  to  normal  active  life,  hence  ultimate 
intervention  must  be  the  rule.  For  reasons  of  economy  of  time,  it 
stands  to  reason  that  the  sooner  the  cure  is  undertaken  the  better. 
At  the  same  time,  as  far  as  my  own  experience  goes,  reasonable  delay 
under  suitable  conditions  has  obvious  advantages.  The  local  con- 
ditions improve  ;  the  collateral  circulation  adapts  itself ;  while,  in 
addition,  delay  allows  the  tissues  to  resiune  as  far  as  possible  their 
natural  state.  The  last  condition  renders  the  surgeon  absolutely 
free  to  undertake  a  plastic  operation  wherever  this  is  possible,  and  in 
the  case  of  the  carotid  vessels  this  is  a  manifest  advantage.  Speak- 
ing generally,  I  think  whenever  the  aneurysm  has  fully  localized  itself, 
operations  should  not  be  midertaken  before  six  wxeks  to  two  months 
have  elapsed  ;  and,  from  the  surgeon's  standpoint,  the  later  he  gets 
the  case  after  this  period,  the  more  likely  is  he  to  have  a  free  hand 
to  perform  an  operation  which  approaches  the  ideal  from  the  recon- 
structive point  of  view. 

Aneurysmal  varices  often  occasion  very  little  trouble  or  dis- 
ability to  the  patient.  The  most  common  indications  for  intervention 
are  the  persistence  of  worrying  noise  in  the  head  or  ears,  or  great 
distention  of  the  vein.  A  large  proportion  of  these  cases  may  be  left 
untouched. 

A  tentative  suggestion  should  perhaps  be  made  as  to  the  advisa- 
bility of  completely  obstructing  the  common  carotid  in  cases  of  arterial 
thrombosis,  wdth  a  view  to  stimulating  the  development  of  the  colla- 
teral circulation.     In  the  only  two  instances  I  have  seen,  a  definite 


166     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

impro\cn-iciit  in  the  symptoms  appeared  to  follow,  and  it  cannot  be 
supposed  that  the  procedure  is  likely  to  cause  any  harm. 

Mode  of  Operation. — In  recent  injuries,  the  nature,  extent,  and 
position  oi'  the  wound  of  the  neck  will  probably  determine  the  incision 
necessary  for  securing  the  artery  ;   but  when  the  operation  is  one  for 


Fig.  43. — Left  carotid  arterio-venous  aneurysm.  Exposure  of  jugular  vein. 
The  vein  completely  covers  the  artery.  The  characteristic  infiltration  and  thickening 
of  the  adventitia  of  the  vein  seen  in  recent  cases  is  well  shown. 


dealing  with  an  aneurysm,  the  incision  needs  to  be  a  very  free  one, 
extending  the  entire  length  of  the  anterior  border  of  the  sternomastoid. 
In  some  instances  it  may  need  to  be  further  extended  by  an  incision 
carried  outwards  from  its  centre,  or  one  along  the  clavicle  from  its  lower 


VESSELS    OF    THE    NECK  167 

angle,  according  to  whether  the  upper  or  lower  portion  of  the  neck  is 
the  seat  of  the  aneurysm.  In  difficult  cases  it  may  also  be  necessary 
to  divide  the  muscles  freely  ;  thus,  the  sternomastoid  may  be  divided 
well  below  the  entrance  of  its  nerve  supply  and  reflected,  the  depressor 
muscles  of  the  hyoid  bone  may  need  to  be  divided,  and  the  omohyoid 
in  most  cases  where  an  aneurysm  has  to  be  dealt  with  in  the  centre 
of  the  neck. 

This  freedom  of  access  is  necessary  as  a  precautionary  measure 
when  the  aneurysm  is  large,  and  also  to  allow  the  upper  and  lower 
portions  of  the  vessel  to  be  exposed  for  the  purpose  of  applying 
provisional  ligatures  to  control  the  circulation  and  permit  the 
necessary  manipulation  of  the  sac  if  a  plastic  operation  is  determined 
upon. 

When  the  actual  field  of  operation  has  been  exposed  by  the 
preliminary  incision,  it  is  best  to  deal  at  once  with  the  veins  crossing 
the  line  of  the  artery.  The  descending  cervical  nerve  should  be 
spared,  if  possible.  The  anterior  jugular  vein  and  the  common  facial 
vein  may  need  to  be  doubly  ligatured  and  divided.  We  are  now  free 
to  deal  directly  with  the  main  vessels.  If  the  aneurysm  be  arterio- 
venous, the  internal  jugular  vein  may  be  very  large,  and,  especially  on 
the  left  side,  may  completely  cover  the  artery  {Fig.  43).  It  may  also 
be  firmly  connected  both  with  the  artery  and  the  sternomastoid  if  the 
latter  has  not  been  divided  and  reflected.  Adhesion  will  be  particu- 
larly intimate  if  the  missile  has  crossed  the  line  of  the  vessels  after 
perforating  the  muscle,  and  it  must  be  remembered  that  separation 
of  the  vein  at  the  point  crossed  by  the  track  may  involve  opening 
up  a  healed  perforation  in  the  wall  of  the  vein. 

Both  artery  and  vein  are  now  isolated  at  the  lower  and  upper 
parts  of  their  course,  and  provisional  ligatures  are  passed  beneath 
and  aroimd  them,  or  around  the  carotid  alone  in  arterial  aneurysm. 
When  this  has  been  done,  the  ligatures  may  be  tightened  sufficiently 
to  control  the  circulation  without  injury  to  the  coats  of  the  vessel, 
and  the  exposure  of  the  sac  proceeded  with. 

Artef^ial  Aneurysm. — When  the  artery  alone  has  to  be  dealt  with, 
further  procedure  is  comparatively  simple.  If  the  case  be  one  of 
only  a  few  weeks'  standing,  the  sac  may  be  readily  separated  from 
the  vessel,  and  the  defect  in  the  wall  exposed  ;  if  the  sac  be  older  and 
firmer,  it  should  be  incised  and  the  defect  in  the  arterial  wall  inspected 
from  within.  If  the  defect  is  now  judged  suitable  for  suture,  it  will 
be  necessary  to  further  mobilize  the  artery  to  facilitate  the  passage 
of  the  stitches,  and  to  reduce  as  much  as  possible  the  local  tension 
when  they  are  tied.  During  the  process  of  mobilization  care  should 
be  taken  to  be  certain  that  there  exists  in  the  arterial  wall  no  second 
wound   which  has  been  reopened   during  the  process  of  freeing  the 


168      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

vessel.  It  is  much  easier  to  overlook  a  second  opening  than  might 
be  supposed,  especially  if  it  is  situated  on  the  posterior  asjDeet  oi" 
the  artery  aiid  not  on  exactly  the  same  level  as  that  first  fomid. 

If  the  defect  in  the  arterial  wall  be  judged  too  extensive  for 
suture,  ligatures  should  be  applied  on  either  side  of  it  in  immediate 
proximity  to  the  opening,  and  tied.  One  ligature  upon  the  vein  is 
now  definitely  tied,  any  remaining  provisional  ligatures  are  withdrawn, 
and  the  woinid  may  be  closed  tightly. 

Arterio-venous  Aneurysm. — The  earlier  stages  of  the  operation 
are  identical  with  those  described  above ;  but  treatment  of  the 
aneurysm  is  a  more  complicated  matter.  ^Vhen  the  aneinysm  is 
connected  with  the  common  carotid  trunk,  it  is  easy  to  abrogate 
completely  the  supply  of  arterial  blood.  It  is  less  easy  in  the  case 
of  the  jugular  vein,  as  branches  may  reach  the  vein  between  the 
points  controlled  by  the  provisional  ligatures.  These  branches  must 
be  sought  for  and  controlled  before  any  further  step  is  taken. 

If  a  sac  be  situated  between  the  artery  and  vein,  it  should  be 
laid  open  and  the  orifices  leading  into  the  tAvo  vessels  inspected.  If 
the  apertures  be  judged  suitable  for  closure  by  suture,  the  vessels  are 
now  more  freely  mobilized,  the  sac  may  be  cut  away,  and  the  openings 
closed.  When  the  sac  is  situated  on  the  aspect  of  the  artery  away 
from  the  vein,  it  is  dealt  with  in  the  manner  already  described  for 
arterial  aneurysms.  Should  this  arrangement  be  found,  the  direct 
opening  which  exists  between  the  artery  and  vein  should  be  dealt 
Avith  as  if  the  ease  were  one  of  imcomplicated  aneurysmal  varix  ; 
that  is  to  say,  the  aperture  should  be  exposed  by  freely  opening  the 
vein  on  the  opposite  side  to  that  uj^on  Avhich  the  conniiunication  Avith 
the  arter}'-  exists,  and  the  adventitious  opening  dealt  wuth  from 
Avithin  the  lumen  of  the  dilated  vein.  Other  arrangements  may  be 
met  Avith  ;  thus,  the  opening  leading  from  the  vein  and  artery  may 
communicate  directly  Avith  a  common  sac,  or  the  sac  may  connect  the 
artery  directly  Avith  one  open  end  of  a  completely  diAdded  A-ein  ;  some 
examples  are  given  beloAv. 

When  the  conditions  are  not  adapted  to  suture,  the  four 
proA'isional  ligatures  already  in  position  may  be  definitely  tightened, 
and  the  sac  may  be  excised.  Care  must  be  exercised  in  the  latter 
procedure  that  important  structiu'es  are  not  damaged  ;  and  it  shoidd 
be  borne  in  mind  that  the  sac  is  a  harmless  struetiu'c,  the  remoA'al  of 
AAhich  is  in  no  sense  obligatory. 

No  material  differences  exist,  except  in  anatomical  detail,  Avhether 
the  internal  or  external  carotid  is  the  seat  of  the  anemysm.  The 
internal  carotid  presents  the  most  difficult  technical  23roblem  Avhen  the 
Avound  is  high  up. 

Should  the   original   injury   haA'C   inA'ohxd   the   common   carotid 


VESSELS    OF    THE    NECK  169 

trunk  immediately  below  the  bifurcation,  in  place  of  apjolying  definite 
ligatures  upon  the  proximal  end  of  the  two  branches,  these  may  be 
completely  divided,  and  an  end-to-end  union  made,  or  a  lateral 
anastomosis  may  be  established,  so  as  to  obtain  the  advantages  of 
conuTiunication  of  the  branches  of  the  two  external  carotids  for  the 
cerebral  supply  through  the  internal  carotid  (Duval). 

Some  of  the  points  involved  in  the  performance  of  these  operations 
may  be  best  illustrated  by  the  short  recital  of  a  few  cases,  and  a  glance 
at  -Figs.  25,  30,  42,  and  44. 

Fig.  42  illustrates  a  point  in  the  formation  of  a  part  of  the  wall 
of  an  aneurysmal  sac  by  inclusion  of  the  remains  of  the  wall  of  the 
artery.  Fig.  44  depicts  the  conditions  which  existed  in  a  case  of 
bilateral  injury  to  the  vessels,  and  this  case,  as  one  of  very  great 
interest  and  importance,  may  be  shortly  detailed. 

Case  27. — Bilateral  injury  of  the  common  carotids.     Use  of  Tuffler  tube. 

A  bullet  entered  at  the  anterior  border  of  the  lower  third  of  the  right 
sternomastoid,  traversed  the  neck,  and  emerged  just  internal  to  the  left 
sternoclavicular  articulation.  The  inner  end  of  the  left  clavicle  was  frac- 
tured. No  serious  primary  haemorrhage  followed  the  wound,  and  the 
patient  after  four  days'  stay  at  a  casualty  clearing  station  was  brought 
down  to  one  of  the  hospitals  on  the  lines  of  communication.  The  condition 
found  on  the  fifth  day  was  as  follows.  A  large  suppurating  wound  was 
present  at  the  root  of  the  neck  on  the  left  side,  and  signs  of  general  toxaemia 
were  of  moderate  degree.  The  entrance  wound  on  the  right  side  of  the  neck 
was  closed  and  quiescent.  A  loud  arterio-venous  bruit,  widely  conducted, 
and  of  which  the  systolic  element  was  the  more  pronounced,  was  heard  at 
the  root  of  the  neck  and  elsewhere.  There  was  no  cardiac  enlargement,  no 
conducted  murmur  to  the  heart,  and  the  pulse  was  100,  and  regular.  The 
patient  developed  a  tetanus  antitoxin  rash,  with  some  fever  ;  and  the 
streptococcal  infection  of  the  wound  at  the  left  side  of  the  neck  progressed, 
so  that  incisions  needed  to  be  made.  Progress  was  not  satisfactory,  and  a 
month  after  reception  of  the  wound  a  fresh  swelling  was  noted  on  the  left 
side  at  the  root  of  the  neck. 

On  examination,  this  proved  to  be  an  arterial  aneurysm,  over  which  a 
faint  systolic  bruit  was  audible.  As  active  infection  of  the  large  wound  in 
immediate  proximity  to  the  recently  developed  aneurysm  was  present,  it 
was  deemed  necessary  to  deal  promptly  with  the  aneurysm,  and  on  the 
next  day  Colonel  C.  Gordon  Watson  operated.  Professor  Tuffier  had  just 
sent  me  some  of  his  silver  junction  tubes,  and  as  a  bilateral  arterial  injury 
was  present  in  this  case,  it  seemed  eminently  desirable  to  deal  as  gently 
with  the  cerebral  circulation  as  possible.  Colonel  Gordon  Watson  therefore 
introduced  a  tube,  which  was  retained  for  three  days,  and  then  removed. 
It  is  doubtful  what  advantage  was  gained  by  the  use  of  the  tube,  as  it 
became  obstructed  within  the  first  twenty-four  hours  ;  but  the  result  attained 
was  good,  since  no  cerebral  signs  developed  in  spite  of  the  presence  of  the 
arterio-venous  aneurysm  on  the  other  side  of  the  neck. 

Unfortunately  the  general  infection  from  which  the  patient  was  suffering 


ITO      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

continued  unchecked,  he  gradually  lost  strength,  developed  an  acute  peri- 
carditis, and  a  month  later  he  died,  death  being  preceded  by  a  transient  loss 
of  power  in  the  right  arm. 

The  condition  of  the  right  vagus  has  already  been  referred  to,  also  the 
remarkable  reproduction  of  a  solid  column  of  tissue  between  the  retracted 
ends  of  the  divided  left  carotid  artery. 


-A-it-1'*^F-'-(^ 


Fig.  4i. — Bilateral  injury  to  the  carotid  arteries.  On  the  right  side,  the  missile 
has  traversed  the  artery,  ^'ein,  and  \'agiis.  The  sheath  of  the  vagus  is  distended  by 
clot,  and  might  eventually  ha\e  formed  tlie  boundary  of  an  aneinysmal  sac.  On  the 
left  side,  an  arterial  aneurysm  which  formed  secondarily  was  operated  upon,  and  a 
Tuffier's  tube  was  introduced.  It  will  be  observed  that  a  column  of  connective  tissue 
corresponding^in  calibre  with  the  tube  now  connects  the  two  extremities  of  the  severed 
artery.      Case  27.      Under  the  care  of  Colonel  Gordon    Watson,  C.M.G. 


VESSELS    OF    THE    NECK  171 

Case   28. — Arteriovenous  aneurysm.     Suture  of  vessels. 

Gun.  R.  Shrapnel  wound  of  right  side  of  neck  ;  missile  retained  at  left 
side  of  first  dorsal  vertebra.  An  arterio-venous  aneurysm  formed,  not 
apparently  of  large  size,  the  signs  being  indistinguishable  from  those  of  a 
simple  varix.  The  signs  were  typical,  and  accompanied  by  those  of  right 
sympathetic  paralysis. 

Nine  weeks  after  reception  of  the  injury,  a  type  operation  was  performed 
as  described  above.  It  was  found  necessary  to  divide  three-fourths  of  the 
width  of  the  sternomastoid  in  order  to  deal  satisfactorily  with  the  lower  end 
of  the  jugular  vein,  for  the  vessels  were  still  somewhat  fixed  as  a  consequence 
of  primary  infiltration  of  the  vascular  cleft  with  blood.  The  vein  was 
large,  but  the  surface  smooth,  and  with  little  signs  of  reactionary  change 
in  the  tissue  of  the  vascular  cleft. 

When  the  circulation  had  been  controlled,  the  vein  was  opened,  as  no 
sign  of  a  sac  was  to  be  seen  from  the  front.  An  opening  in  the  back  of  the 
vein  was  disclosed,  communicating  with  a  sac  lying  behind  the  vessels  and 
in  the  substance  of  the  prevertebral  muscles.  Both  vessels  were  now 
mobilized,  and  the  artery  was  found  to  have  an  oblique  slit  on  its  postero- 
internal aspect,  and  communicated  by  this  opening  with  the  sac  lying 
behind  the  vessels.  The  arterial  defect  was  closed  by  suture,  and  the 
opening  in  the  vein  sewn  up  from  the  interior  of  the  vessel  ;  lastly,  the 
exploratory  incision  in  the  vein  was  closed,  and  the  repair  was  completed. 
The  sac  was  practically  left  untouched,  except  that  it  was  separated  from 
the  artery  (G.  11.  M.). 

It  was  noted  that  on  the  day  after  the  operation  the  man  sweated 
freely  except  on  the  right  side  of  his  face.  Except  for  some  anaesthetic 
sickness  he  made  an  uninterrupted  recovery,  and  as  far  as  can  be  judged 
the  vessels  have  remained  patent.  The  sympathetic  paralysis  steadily 
improved. 

Case  29. — Arterio-venous  aneurysm  of  left]  internal  carotid  artery. 
Suture  of  vessels. 

Sergt.  P.  A  piece  of  shrapnel  case  entered  at  the  left  angle  of  the 
inaudible,  and  was  retained  opposite  the  disc  between  the  third  and 
fourth  cervical  vertebrae.  An  arterio-venous  aneurysm  formed  {Fig.  45), 
associated  with  left  sympathetic  paralysis.  The  signs  were  typical,  but  it 
was  impossible  to  determine  whether  the  internal  or  the  external  carotid 
was  involved. 

Six  weeks  later  the  aneurysm  was  explored  ;  the  sac  proved  to  be 
a  junction  chamber  interposed  between  the  internal  jugular  vein  and  the 
lower  end  of  the  internal  carotid  artery.  When  the  control  ligatures  had 
been  tightened  up,  the  sac  was  laid  open,  but  fairly  free  bleeding  took  place, 
the  blood  apparently  being  furnished  by  the  ascending  pharyngeal  and 
superior  thyroid  arteries,  each  of  which  needed  to  be  freed  and  controlled 
by  an  arterial  clamp.  The  opening  in  the  vein  was  easily  sewn  up,  but  as 
the  field  of  operation  could  not  be  kept  free  of  blood  on  the  arterial  side,  in 
place  of  removing  the  remains  of  the  small  sac,  sutures  were  passed  through 
it,  and  thus  it  M^as  plicated  and  closed  (G.  H.  M.). 

The  future  progress  was  uneventful,  except  that  some  enlargement  was 
found  to  be  present  at  the  site  of  the  sac  when  the  patient  had  his  wound 
dressed  a  week  later.  This  enlargement  was  exaggerated  by  induration  of 
the  surrounding  tissues,  and  over  it  a  somewhat  harsh  systolic  bruit,  much 
increased  in  loudness  by  pressure  of  the  stethoscope,  was  heard. 


172     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

'IMic  i)aticnt  was  ii])  and  about  at  the  end  of  throe  weeks,  and  the  local 
condition  lias  steadily  improved.  I  think  the  ])Iication  of  the  sac  was  a 
mistake.  allhoui>li  it  much  facilitated  the  o])eration. 


Fifj.  45. — Arterio-venous  aneurysm  of  common  carotid.  The  small  prominent 
nodule  is  merely  the  characteristic  thickening  around  the  wovmd  track  often  seen 
in  the  early  stages. 


Case   30. — Arterio-venous  aneurysm.    Suture  of  vessels. 

Lieut.  A.  A  bullet  wound  was  followed  by  prompt  de\elopment  of 
the  aneurysm.  The  patient  was  only  retained  in  France  for  a  few  days. 
He  remained  in  hospital  for  some  time,  was  then  discharged,  and  led  an  easy 
life  for  more  than  a  year.  The  main  trouble  experienced  was  the  buzzing 
noise  in  the  head  and  opposite  ear.  No  active  exertion  had  been  made  since 
the  date  of  injury. 

The  signs  were  typical,  with  associated  sympathetic  paresis.  Fourteen 
months  later  an  exploration  was  made.  The  sac  was  found  to  be  small  and 
interposed  between  the  two  vessels.  The  whole  operation  Avas  one  of  great 
simplicity  on  account  of  the  time  which  had  been  allowed  to  elapse  before 


VESSELS    OF    THE    NECK 


173 


it  was  undertiiken.  The  sac  was  incised,  the  wound  in  the  vein  sewn  up, 
and  the  same  course  taken  with  the  artery.  Uninterrupted  progress  ended 
in  complete  recovery  (G.  II.  M.). 


h-i;A 


Fig.   46. 


-The  wounds  in  the  vessels  oi  tne  arterio-venous  aneurysm  shown  in 
Fig.  45.      The  tubercle  has  been  retracted  backwards. 


Case  31 . — Arterio-venous  aneurysm.     Suture  of  artery,  ligature  of  vein. 

Gun.  C.  A  fragment  of  shrapnel  case  entered  just  behind  the  anterior 
border  of  the  sternomastoid  of  the  left  side,  and  lodged  against  the  vertebrae^ 
on  the  left  side  of  the  mid-line.  A  typical  arterio-venous  IiEematoma  resulted. 
It  was  soft  and  rather  extensive,  with  indefinite  margins.  Twelve  days 
later  it  was  explored.  No  definite  sac  had  formed,  but  the  haimatoma  was 
sufficiently  well  localized  to  allow  the  provisional  ligatures  to  be  applied 
without  any  great  difficulty.  When  the  vessels  were  exposed,  a  perforation 
was  seen  on  the  antero-external  aspect  of  the  upper  third  of  the  common 
carotid  artery,  and  a  laceration  of  the  vein.  Troublesome  bleeding  from 
the  vein  necessitated  double  ligature  of  that  vessel.  I'he  artery  was  mobil- 
ized, not  without  some  difficulty  on  account  of  the  induration  of  the  areolar 
tissue  of  the  vascular  cleft.  The  visible  defect  in  the  wall  was  then  sutured, 
and  the  blood  allowed  to  enter  the  vessel  from  above.     This  act  was  followed 


174      GUNSHOT    IX JURIES    TO    THE    BLOOD-VESSELS 

liy  free  liaenu)rrlia<ic  from  the  back  of  the  vessel.  The  ii])pcr  provisional 
ligature  was  atjain  tiolitened,  and  on  examination  a  second  oIjHcjuc  slit  in 
the  j)osteriof  aspect  of  the  vessel,  which  had  been  closed  by  adhesion  to  the 
prevertebral  fascia,  was  found  to  liave  been  reopened  in  the  process  of 
mobilization  of  the  vessel.  This  second  slit  was  repaired  with  some  difli- 
culty,  and  the  wound  closed  (G.  H.  M.).  The  patient  made  an  uninter- 
rupted recovery. 

Case   32. — Arterio-venous  aneurysm.     Suture.    Failure  to  cure  varix. 

Pte.  L.  Bullet  wound  of  neck.  Type  minimal  wounds  of  entry  and 
exit,  passing  from  behind  the  centi'e  of  the  left  sternomastoid  to  emerge  near 
the  mid-line  at  the  level  of  the  cricoid.  A  typical  arterio-venous  aneurysm 
developed  at  the  level  of  the  cricoid  cartilage,  the  sac  extending  towards 
the  mid-line. 

Three  months  later  an  operation  was  undertaken.  The  soft  parts  had 
in  great  measure  regained  their  normal  state,  and  little  difficulty  was  experi- 
enced in  defining  the  sac,  which  lay  to  the  inner  side  of  the  artery.  As  I  felt 
confident  that  a  direct  communication  was  present  between  the  internal 
jugular  and  the  artery,  I  opened  the  vein  as  a  preliminary  procedm-e.  I 
found  no  opening.  The  artery  was  then  mobilized,  and  separated  from  the 
sac,  with  which  it  communicated  by  an  elongated  slit  on  its  inner  aspect. 
When  the  interior  of  the  artery  was  inspected  from  this  opening,  a  small 
opening  on  the  opposite  side  filled  with  clot  was  seen.  A  probe  would  not 
enter  this  aperture,  and  I  was  inclined  to  think  it  the  blocked  origin  of  a 
superior  thyroid  branch  placed  in  an  abnormal  position.  The  operation 
was  then  completed,  but  as  a  very  long  slit  had  been  made  in  the  jugular 
vein,  the  provisional  ligatures  were  made  definite  and  the  intervening 
portion  of  vein  was  excised  (G.  H.  M.). 

Three  daj^s  afterwards  the  patient  complained  of  an  attack  of  pain  in 
the  neck,  and  the  dressings  were  removed.  Examination  showed  that  the 
arterio-venous  bruit  had  returned,  and  the  veins  at  the  root  of  the  neck 
pulsated  freely.  No  evidence  existed  during  the  next  three  months  of 
recurrence  of  the  arterial  sac,  but  the  bruit  persisted,  although  the  pulsation 
of  the  veins  at  the  root  of  the  neck  diminished  in  force.  The  patient  declined 
any  further  intervention,  and  returned  to  Canada. 

Choice  of  Method. — It  is  in  the  case  of  the  carotid  vessels  that 
the  question  of  hgature  or  repair  by  suture  acquires  chief  importance. 
The  advantages  on  the  side  of  hgature  may  be  stated  as  consisting  in  : 

(a)  Its  ease  and  rapidity  of  apphcation,  suiting  it  to  those  cases  in 
which  a  short  operation  is  a  desideratiun  which  can  be  considered  to 
counterbalance  the  risks  of  disturbance  of  the  cei-ebral  circulation  ; 

(b)  The  fact  that  the  operation  is  generally  applicable,  and  can  be 
performed  in  many  cases  in  which  suture  is  impracticable. 

Whenever  it  is  determined  to  ligatiu'c  the  common  carotid  or  its 
branches,  simultaneous  occlusion  of  the  vein  should  always  be  a  part 
of  the  operation.  It  has  proved  certain  that  occlusion  of  the  satellite 
vein  is  advisable  in  dealing  with  the  arteries  of  the  extremities,  and  if 
the  explanation  be  fomid  in  the  reduction  of  the  degree  of  ansemia 
consequent  on  interference  Avith  the  arterial  sTipi:)ly,  it  is  clear  that 


VESSELS    OF    THE    NECK 


175 


the  procedure  is  doubly  advisable  in  the  case  of  one  of  the  chief 
sources  of  the  blood-supply  of  the  brain.  The  few  lionrcs  I  have  to 
offer  in  the  case  of  this  artery  are  at  least  suggestive,  since  they  refer 
to  a  consecutive  series,  even  if  few  in  number. 


Ligature  of  artery  and  vein 
Ligature  of  artery  alone 


Cerebral  Complications 


2*      (22-2  per  cent) 
5        (27-7  „       ) 


*  One  of  these  patients  was  very  exsanguine  when  operated  upon  on  the  second 
day  after  receipt  of  the  injury. 


Fortunately  the  common  carotid  artery  is  not  only  one  in  which 
a  reconstructive  operation  of  repair  is  advisable,  but  it  is  also  the 
easiest  artery  in  the  body  to  deal  with,  on  account  of  its  size,  the  ease 
with  which  its  entire  course  can  be  exposed,  the  readiness  with  which 
it  can  be  mobilized,  and  the  fact  that  it  gives  off  no  branches  except 
its  two  terminal  divisions.  Again,  the  size  and  direct  course  of  the 
internal  jugular  vein  renders  it  a  very  easy  vessel  to  manipulate. 

It  will  be  noted  in  the  description  of  the  operation  furnished 
above,  that  the  method  has  been  limited  to  the  treatment  of  injuries 
of  a  perforating  or  lateral  character.  I  may  say  at  once  that  more 
extensive  injuries  may  readily  be  dealt  ^vith  by  resection  and  end-to- 
end  union  of  the  vessel.  I  have  no  personal  experience  of  the  length 
of  the  vessel  which  may  be  sacrificed  and  yet  a  safe  end-to-end  union 
be  effected,  but  possibly  at  least  three-quarters  of  an  inch  may  be 
resected  and  the  union  established  without  difficulty.  The  apjolica- 
bility  of  this  form  of  operation  depends  entirely  on  the  technical 
capacity  of  the  operator  ;  my  ow^n  experience  of  it  is  limited  to  the 
brachial  artery,  an  easy  vessel  to  manipulate  ;  but  I  have  not  always 
been  fortunate  in  avoiding  the  ultimate  occurrence  of  thrombosis.  In 
the  case  of  the  carotid,  as  has  been  already  pointed  out,  it  is  extremely 
difficult  to  determine  whether  occlusion  has  taken  place  or  not ;  hence 
in  the  short  series  of  cases  I  have  to  report  I  am  not  prepared  to  assert 
that  the  viability  of  the  vessels  was  permanently  attained,  although 
the  results  are  to  all  appearance  of  a  satisfactory  nature.  There  is, 
moreover,  nothing  to  show  that  anything  is  lost  by  the  attempt  to 
obtain  an  ideal  result,  and  suture  of  the  wounded  carotid  should,  in 
my  opinion,  always  be  undertaken  if  practicable. 

The  simplest  of  all  the  operations  is  that  for  the  cure  of  an 
aneurysmal  varix  ;  and  if  it  be  undertaken,  the  rule  of  approaching 
the  aperture  of  communication  by  way  of  the  vein,  after  establishing 
provisional  control  of  the  blood-current,  should  always  be  observed. 


170      GUNSHOT    IXJi'lUES    TO    THE    BLOOD-VESSELS 

WOUNDS   OF  THE   SMALLER  ARTERIES  OF  THE  NECK. 

The  oijy  importance  pertaining  to  wounds  of  the  sniaUer  vessels 
of  the  neck  consists  in  the  difficulty  which  may  arise  in  discriminating 
between  anem-ysms  which  may  develop  in  connection  Avith  them, 
and  aneurysms  originating  in  wounds  of  the  main  trunks.  Cases-  12 
and  15  illustrate  this  point  with  regard  to  the  superior  and  inferior 
thyroid  arteries  respectively,  and  emphasize  the  need  for  careful 
exploration,  lest  the  main  trunk  be  hastily  and  needlessly  sacrificed. 

I  have  seen  aneurysms  in  connection  with  the  occipital,  the  facial, 
and  the  temporal  arteries,  but  these  need  no  further  description. 

The  vertebral  artery  requires  more  detailed  attention,  for  the 
depth  of  its  situation  renders  it  difficult  in  many  cases  either  to  dia- 
gnose the  injury  or  to  deal  with  it  surgically.  I  only  came  across  3 
cases.  In  2  of  these  the  aneurysm  developed  in  connection  with  the 
commencement  of  the  vessel ;  in  the  third  the  artery  had  been 
injured  in  the  part  of  its  course  lying  upon  the  arch  of  the  atlas. 

Neither  of  the  two  cases  of  injury  of  the  lower  end  of  the  vessel 
I  saw  were  operated  upon,  as  the  sac  was  small,  no  pulsation  was  pal- 
pable, and  the  patients  appeared  to  suffer  little  or  no  disability.  The 
diagnosis  was  made  upon  the  softness  and  apparent  dei^th  of  the 
murmur,  in  both  cases  a  pure  systolic  one,  and  the  absence  of  evidence 
of  injury  to  either  the  carotid  or  subclavian  artery  ;  in  one  of  them 
the  existence  of  a  fracture  of  the  transverse  process  of  the  7th  cervi- 
cal vertebra,  as  seen  by  cr-ray  examination,  supported  the  diagnosis. 
The  third  case  was  operated  upon  by  Colonel  Harvey  Cushing.  The 
sac  was  exposed  in  the  sub-occipital  triangle,  and  as  it  was  foimd 
impracticable  to  apply  a  ligature  locally,  the  sac  was  plugged,  and  the 
artery  was  secured  at  the  root  of  the  neck.  The  operation  was 
successful. 

With  no  operative  experience  on  the  subject,  I  am  loth  to  dogma- 
tize upon  the  best  route  to  choose  when  a  vertebral  aneurysm  at  the 
root  of  the  neck  needs  to  be  dealt  with.  Should  I  need  to  operate  on 
such  a  case,  I  should  prefer  to  make  the  angular  incision  as  for  the 
innominate  artery  or  the  first  portion  of  the  subclavian  artery,  and 
partially  or  wholly  divide  the  sternomastoid  muscle,  in  order  to  ensiu-e 
sufficient  room  for  a  comfortable  exposure  of  the  sac.  If  the  route 
from  the  posterior  border  of  the  sternomastoid  be  chosen,  less  space 
is  secured,  and  probably  a  much  wider  division  of  tissues  becomes 
necessary. 

SUBCLAVIAN    ARTERY. 
Twenty-eight  cases  of  injury  to  the  subclavian  artery  are  included 
in  the  series.     Wounds  of  this  vessel  are  not  met  with  so  frequently 
in  hospitals  as  those  of  the  carotid  or  axillary.     This  depends  partly 


VESSELS    OF    THE    NECK  177 

on  the  comparative  shortness  of  the  course  the  trunk  runs,  [>ut  also 
in  part  on  the  dangerous  nature  of  the  accident.  Although  situated 
deeply,  and  in  the  greater  part  of  its  course  protected  both  by  bones 
and  muscles,  in  its  first  part  it  is  in  very  close  relation  with  other 
great  vessels,  a  concurrent  wound  of  which  is  probably  usually  fatal  ; 
and  further,  its  relation  to  the  apex  of  the  pleural  sac  is  an  arrange- 
ment which  allows  internal  haemorrhage  to  take  place  quietly  and 
easily,  and  to  be  abiuidant  in  amount. 

The  artery  of  the  right  side  was  involved  in  16  of  the  injuries, 
and  that  of  the  left  in  only  12,  in  spite  of  the  longer  course  taken 
by  the  latter  vessel.  In  24  of  the  cases  in  which  the  nature  of 
the  missile  is  recorded,  it  was  a  bullet  in  15,  and  a  fragment  of 
shell  in  9.  Of  the  wounds  of  the  soft  parts,  13  were  narrow  through- 
and-through  tracks  ;  in  8  instances  the  missile  was  retained  ;  in  2 
the  wounds  were  large  ;  in  one  of  the  patients  with  a  large  wound, 
infection  and  secondary  haemorrhage  proved  fatal. 

In  7  of  the  patients  (25  per  cent)  free  primary  haemorrhage 
is  noted  to  have  occurred  ;  in  this  relation  it  may  be  added  that  in 
9  more  a  large  hsemothorax  complicated  the  injury.  Secondary 
haemorrhage  from  the  wound  only  occurred  twice,  and  in  each 
instance  it  proved  fatal.  Extension  of  the  hsematoma  formed  the 
indication  for  operative  intervention  in  4  cases. 

The  complication  of  hgemothorax  does  not  appear  to  have 
materially  affected  the  prognosis  in  patients  reaching  the  hospitals 
on  the  lines  of  communication  ;  it  was  present  in  10  of  the  28 
cases  (35-7  per  cent),  6  times  in  the  right,  4  times  in  the  left  pleura, 
and  none  of  the  patients  died,  although  in  one  instance  the 
blood  became  infected  and  an  empyema  needed  to  be  treated.  The 
association  with  wounds  of  the  chest  was  approximately  as  common 
in  injuries  to  the  axillary  artery  (20  per  cent),  but  injuries  to  that 
vessel  do  not  furnish  the  blood  for  the  pleural  effusion.  The  same 
may  be  the  case  with  the  subclavian  when  the  missile  enters  deeply, 
or  traverses  the  thorax ;  but  in  a  certain  mmiber  of  cases  the 
subclavian  is  the  source  of  the  blood  which  collects  in  the  ^^leura. 
I  obtained  post-mortem  evidence  of  this  fact  in  a  case  observed  during 
tlie  South  African  War,  and  certain  points  in  the  clinical  history  of 
the  patients  under  consideration  support  the  statement.*  First,  it 
may  be  remarked  that  none  of  the  subclavian  aneurysms  in  this 
series  was  of  large  size  ;  but  when  the  cases  are  analyzed,  this  is  a 
specially  well-marked  feature  in  those  in  which  a  hacmothorax  was 
present.  Of  10  cases  of  injiu-y  to  the  artery  accompanied  by  a 
hacmothorax,  in  only  2  did  a  well-marked  rounded  tumour  develop  ; 


*  See  Case  32a,  p.  188.  12 


178     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

in  o  no  aneurysmal  tumour  or  abnormal  pulsation  was  detected,  in  2 
the  signs  pointed  to  local  thrombosis  of  the  artery,  and  in  4  slioht 
or  diffuse  abnormal  pulsation  was  the  only  other  sign  to  corroborate 
the  evidence  rurnished  by  the  presence  of  a  local  vascular  mm-mnr. 
Further,  in  all  the  cases  the  local  signs  were  but  slightly  marked  in 
the  initial  stage,  and  tended  to  increase,  and  in  two  of  the  ha^mothorax 
cases  the  tmiiour  was  not  detected  imtil  a  later  date — in  one  instance 
only  at  the  end  of  three  weeks.  In  those  instances  in  Avhich  the 
subclavian  really  fm'nishes  the  blood  for  the  hcTmothorax,  I  think 
the  late  development  of  the  tumour  finds  a  ready  exjilanation.  The 
direction  of  least  resistance  for  the  passage  of  the  blood  is  obviously 
towards  the  potential  space  afforded  by  the  pleural  sac,  and  it  is  only 
Avhen  a  certain  degree  of  distention  of  this  has  been  reached  that  any 
blood  will  travel  into  the  tissues  of  the  neck.  Hence  the  clot  which 
ordinarily  forms  the  initial  boundaries  of  a  hfematoma  is  only 
deposited  at  a  late  date,  and  may  not  surroimd  any  blood-cavitj^ 
or  a  sac  may  be  practically  absent. 

The  second  common  complication  consists  in  injiuy  to  the  cords 
of  the  brachial  plexus.  Signs  of  serious  damage  to  the  nerves  were 
present  in  7  cases  (25  per  cent),  and  in  3  others  severe  pain  in  the 
upper  extremity  pointed  to  injury  of  a  minor  degree.  I  have  but 
few  details  as  to  the  ultimate  result  in  any  of  these  cases,  but 
I  doubt  if  they  are  as  bad  as  those  seen  after  injuries  to  the  vessels 
and  nerves  of  the  axilla.  Of  the  10  cases  in  which  nerve  implica- 
tion was  noted,  4  were  of  the  vessel  in  the  second  part  of  its  course, 
and  6  in  the  third  part  ;  in  three  of  the  latter  pain  was  the  only 
sign  present. 

In  3  cases  a  fractured  clavicle  was  present,  in  4  a  fracture  of 
the  upper  part  of  the  scapula,  and  in  1  a  fractured  humerus  and 
acromion  process. 

Of  the  whole  series  of  28  injuries,  4  (14-2  per  cent)  were  to  the 
first  part  of  the  artery,  13  (46-2  per  cent)  were  to  the  second,  and 
10  (35-7  per  cent)  to  the  third.  I  think  this  distribution  corresponds 
fairly  accurately  with  the  relative  danger  attendant  upon  injury  in 
the  three  positions. 

As  to  the  nature  of  the  lesions  of  the  vessels,  in  2  spontaneous 
thrombosis  probably  took  place  ;  this  was  evidenced  in  one  by  the 
deposition  of  an  embolus  at  the  bifurcation  of  the  brachial  artery, 
and  in  the  second  by  signs  of  arterial  obstruction  unaccompanied 
by  either  swelling,  pulsation,  or  an  arterial  bruit.  In  3  cases 
operation  showed  the  artery  to  have  suffered  complete  severance  of 
continuity  ;  and  in  one  of  these — discovered  during  an  early  explora- 
tion of  a  divided  brachial  jalexus — there  was  no  evidence  of  any  local 
hcemorrhage  having  taken  place.     The  form  and  extent  of  the  injury 


VESSELS    OF    THE    NECK  179 

in  the  remaining  cases  can  only  be  conjectured,  but  in  three  opera- 
tions for  arterial  hfematoma  it  was  found  that  cither  the  vein  had 
been  wounded  or  its  continuity  severed  without  the  development 
of  an  arterio-venous  communication  taking  place.  This  latter  fact 
is  in  consonance  with  the  remark  made  in  the  general  section  as 
to  the  importance  of  retention  of  continuity  of  the  vein,  and  of  its 
close  proximity  to  the  artery,  in  determining  the  occurrence  of 
aneurysmal  varices  or  arterio-venous   aneurysms. 

In  24  of  the  cases  either  an  arterial  or  an  arterio-venous  hamia- 
toma  formed.  In  13  of  these  the  signs  pointed  to  a  pure  arterial 
injury  ;  in  one  of  these,  disappearance  of  both  pulsation  and  bruit 
appeared  to  indicate  a  spontaneous  cure.  In  11  cases  an  arterio- 
venous communication  was  established  ;  in  only  one  of  these  was  a 
large  ha^matoma  present,  and  the  presence  of  the  tyj^ical  murmur 
was  an  important  element  in  the  diagnosis. 

Little  remains  to  be  said  as  to  the  sjDecial  characters  of  aneurysms 
of  this  artery  ;  the  general  tendency  is  to  be  small,  and  this  is  most 
marked  in  those  in  connection  with  the  second  portion  of  the  artery. 
In  those  of  the  third  portion  the  posterior  triangle  offers  easier 
conditions  for  the  formation  of  a  ha?matoma.  When  the  aneurysm  is 
arterio-venous,  the  large  size  of  the  vein,  and  the  powerful  suction 
action  exerted  on  the  venous  circulation  in  such  close  j^roximit}^  to 
the  upper  opening  of  the  thorax,  do  much  to  relieve  the  pressure  of 
the  arterial  blood-stream,  and  probably  account  in  considerable 
measure  for  the  fact  that  large  sacs  do  not  form. 

Amongst  23  of  the  cases,  the  radial  pulse  was  obliterated  in 
9,  in  some  of  which  it  returned  ;  while  in  14  it  was  present,  but 
diminished  in  volume. 

The  presence  of  the  characteristic  murmurs  is  the  most  valuable 
and  dependable  sign  of  a  wound  of  the  artery  or  an  arterio-venous 
communication  ;  if  these  be  absent,  or  disappear  in  association  with 
obliteration  of  the  radial  pulse,  local  thrombosis  may  be  assumed. 
In  two  cases  of  the  series  the  systolic  murmur  was  transferred  to  the 
cardiac  apex. 

The  most  difficult  point  in  diagnosis  is  to  distinguish  injuries  of 
the  first  part  of  the  artery  from  those  of  the  root  of  the  carotid,  and 
on  the  right  side  from  those  of  the  innominate  arterj^.  Careful 
auscultation  for  the  point  at  which  the  local  murmur  is  loudest,  and 
— in  arterio-venous  communications — observation  of  which  set  of 
veins  pulsates,  are  the  main  aids  ;  but  a  certain  clinical  diagnosis  can 
hardly  be  established. 

Prognosis  and  Treatment.  —  Examination  of  the  methods  of 
treatment  adopted  in  this  series  affords  a  \e\y  restricted  amount  of 
information,  although,  such  as  it  is,  the  experience  furnishes  matter 
for  serious  consideration. 


ISO      GUNSHOT    L\ JURIES    TO    THE    BLOOD-VESSELS 

The  great  majority  of  the  patients,  while  under  my  observation, 
Avere  treated  by  rest,  and  afterwards  transferred  to  England  ;  and  I 
regret  being  unable  to  obtain  a  further  history  of  more  than  i'our 
of  these,  in  spite  of  the  valuable  aid  given  to  me  by  Dr.  Young. 

One  of  the  patients,  in  whom  spontaneous  thrombosis  oceurrcd. 
eventually  returned  to  active  service,  and  was  serving  with  his 
battalion  in  France  sixteen  months  later  ;  in  this  case  there  was 
a  htemothorax,  but  no  signs  of  nerve  injury. 

A  second  case  was  operated  upon  on  return  to  England,  the 
arterio-venous  commimication  proving  to  be  axillary.  No  report  as 
to  further  progress  is  available,  except  that  the  radial  pulse  had 
returned  four  months  later,  and  that  discharging  wounds  were  still 
open. 

In  a  third,  a  note  suggests  that  in  England  the  surgeon  was 
inclined  to  attribute  the  injury  to  the  arch  of  the  aorta.  "  Loud 
murmur  over  region  of  ascending  arch  and  superior  vena  cava — 
a;-ray  examination  shows  the  arch  of  the  aorta  to  be  a  narrow  one, 
otherwise  there  is  nothing  abnormal  to  be  seen — the  patient  is  very 
weak  and  incapable  of  exertion."  In  France,  a  month  earlier,  I  have 
the  note,  "  loud  machinery  murmur,  loudest  over  clavicle  ;  conducted 
to  the  base  of  the  heart,  the  neck,  and  down  the  limb,"  and  I  am 
still  inclined  to  locate  the  injury  to  the  right  subclavian. 

Seven  patients  were  operated  upon  ;  in  each  instance  the  indica- 
tion was  either  h.xmorrhage  from  the  wound,  or  increase  in  size  of 
the  htematoma  ;  and  in  every  case  a  fatal  issue  followed.  In  view 
of  the  very  great  danger  which  attends  these  oiDcrations,  the  most 
useful  plan  is  to  append  a  short  rej^ort  of  each. 

Case  33. — Arterial  liaematoma.  Haemorrhage  folio-wing  removal  of 
retained  missile.      Secondary   bleeding.      Death. 

A  piece  of  shrapnel  case  was  removed  from  the  left  posterior  triangle 
of  the  neck  three  days  after  reception  of  the  wound.  The  opei'ation 
was  accompanied  by  free  bleeding,  which  was  checked  by  plugging  the 
wounds. 

Cellulitis  followed,  and  on  the  tenth,  twelfth,  and  fourteenth  days  a 
haemorrhage  accompanied  each  dressing  of  the  wound,  which  was  phigged 
on  each  occasion.  On  the  fifteenth  day  an  attempt  to  reach  and  ligature 
the  artery  was  made,  but  the  matted  condition  of  the  tissues  was  such 
that  in  the  face  of  incontroUable  bleeding  the  operation  had  to  be  aban- 
doned and  the  wound  again  plugged.  The  patient  died  of  exhaustion 
about  twelve  hours  later.  A  diagrammatic  drawing  of  the  arterial  wound 
in  this  ease  is  shown  in  Fig.  8  c. 

At  the  post-mortem  examination,  a  large  mass  of  blood-elot  was 
found  beneath  the  clavicle,  also  suppuration  extending  into  the  neck 
and  downwards  in  the  posterior  mediastinum.  Two  inches  of  the  sub- 
clavian vein  were  missing,  and  the  arterial  wound  was  of  'flap'  form. 
Neither  arterial  nor  arterio-venous  bruit  had  been  audible  durinjj  hfe. 


VESSELS    OF    THE    NECK  181 

Case  34. — Arterial  haematoma.  Haemorrhage  following  removal  of 
retained  missile   on  day  of  w^ound.    Secondary  bleeding.     Death. 

Pte.  C.  At  the  first  dressing  performed  at  the  casualty  clearuig  statif)ri, 
bleeding  followed  removal  of  the  plug  introdueed  at  the  [primary  operation. 
The  wound  was  repacked,  and  the  skin  brought  together  over  the  plug  by 
stitches. 

On  arrival  at  a  hospital  on  the  lines  of  communication  on  the  fifth 
day,  the  plugs  were  again  removed  and  no  haemorrhage  followed.  On  the 
seventh  day  a  copious  secondary  haemorrhage  occurred  ;  the  wound  was 
again  plugged,  not  sufficiently  tightly,  however,  to  obliterate  the  radial 
pulse.  On  the  seventeenth  day  haemorrhage  again  recurred,  and  an 
attempt  to  secure  the  subclavian  artery  was  made.  The  tissues  were 
matted  and  soft,  but  a  ligature  was  passed  around  the  third  portion  of  the 
subclavian,  and  haemorrhage  was  arrested.  The  operation  was  very 
difficult,  and  some  air  entered  the  pleura  during  its  performance.  The 
patient  died  the  same  evening  from  exhaustion  and  loss  of  blood. 

These  two  operations  merely  emphasize  the  advisability  of 
dealing  radically  with  haemorrhage  from  the  root  of  the  neck  at  the 
primary  operation  on  the  wound. 

The  remaining  five  operations  were  all  performed  for  some  form 
of  aneurysm.  Two  of  the  fatal  results  occurred  in  cases  operated 
upon  by  myself,  and  I  will  place  these  first,  as  well  illustrating  the 
dangers  which  may  have  to  be  faced. 

Case  35. — False  aneury.sm  of  second  portion  of  subclavian  artery. 
Local  ligature.     Death  from  effects  of  haemorrhage. 

Pte.  B.  was  admitted  three  days  after  being  wounded  by  a  bullet  which 
entered  about  the  apex  of  the  right  posterior  triangle  and  emerged  at  the 
back  of  the  shoulder  above  the  posterior  margin  of  the  scapula.  The  entry 
wound  was  minimal  in  size.  There  was  a  complete  brachial  monoplegia. 
A  large,  soft,  pulsating  swelling  extended  upwards  to  the  level  of  the  top 
of  the  thyroid  cartilage,  raised  the  sternomastoid  slightly,  but  did  not 
extend  beneath  the  trapezius.  The  radial  pulse  was  absent.  A  simple 
systolic  bruit  was  audible  throughout  the  swelling,  but  was  not  widely 
conducted.     The  man  was  very  pale  and  anaemic. 

During  the  next  fourteen  days  complete  rest  was  maintained,  and 
the  swelling  became  much  more  localized  ;  but  on  the  thirteenth  day  it 
was  noted  to  be  much  softer  and  apparently  increasing.  For  the  latter 
reasons  I  decided  to  operate  in  spite  of  the  patient's  anaemic  condition.  As 
a  precaution,  the  innominate  artery  was  first  exposed  by  an  incision  along 
the  anterior  border  of  the  sternomastoid,  and  a  clamp  was  placed  upon  it. 
An  incision  was  now  carried  from  the  lower  end  of  the  first  one,  along  the 
clavicle,  and  a  triangular  flap  raised  outwards.  The  swelling  was  then 
exposed  and  opened.  A  cavity  containing  a  greenish  fluid,  bounded  by 
decolorized  lymph,  was  found  completely  shut  off  from  a  deeper  swelling  by 
the  deep  layers  of  the  cervical  fascia.  The  aneurysm  was  then  opened,  a 
procedure  which  was  followed  by  an  alarming  rush  of  blood,  controlled  only 
by  pressure  downwards  and  inwards  towards  the  transverse  processes  of  the 
cervical  vertebrae.  After  some  trouble  the  bleeding,  which  came  from  the 
central  end  of  a  complete  division  of  the  artery  in  its  second  portion,  was 
stopped,  and  it  was  thought  wiser  to  tie  the  first  portion  of  the  subcla^^an 


182      GUNSHOT   INJURIES    TO    THE   BLOOD-VESSELS 

trunk,  and  remove  tlie  clamp  from  the  innominate.  No  trace  of  the  sub- 
clavian vein  was  seen.  The  patient  was  much  blanched  froni  loss  of  blood 
at  the  end  of  the  operation,  and  three  hours  later  he  died,  in  spite  of  a 
saline  infusion  (G.  H.  M.). 


Fig.  47. — Arterial  aneurysm  developed  in  connection  with  a  complete  division 
of  the  second  portion  of  the  right  subclavian  artery.  The  distal  end  of  the  vessel  is 
shown  by  the  dark  glass  rod.  The  white  rod  passes  through  the  original  aperture 
of  entrance  of  the  bullet,  and  indicates  its  coiu-se.  The  anterior  scalene  muscle  was 
destroyed  in  half  its  width  by  the  bullet.  The  incision  in  the  sternal  portion  of  the 
sternomastoid  muscle  was  made  for  the  purpose  of  applying  an  arterial  clamp  to  the 
innominate  artery  during  the  progress  of  the  operation  on  the  aneurysm.  Under 
the  care  of  Dr.  Bonald  Gray. 


VESSELS    OF    THE    NECK 


183 


Fig.  47  shows  the  condition  found  at  the  operation.  One  [)rjir)t,  the 
destruction  of  half  the  width  of  the  anterior  scalene  muscle,  the  phrenic 
nerve  lying  intact  on  the  fascia  at  the  very  edge  of  the  reniaiuirig  part, 
is  instructive,  since  had  the  muscle  been  divided — as  was  at  one  moment 
contemplated  during  the  difficulties  of  the  operation— the  nerve  might 
not  have  escaped.  The  hsemorrhage  came  from  the  return  flow  in  the 
branches  of  the  first  and  second  parts  of  the  artery. 

Special  points  of  interest  in  this  case  are,  firstly,  that  the  space 
occupied  by  the  original  ha^matoma  had  become  loculated  and  the 
lociilus  shut  off,  while  a  typical  false  aneurysm  had  developed  ; 
secondly,    that    although    both    the   vein    and    artery   had    suffered 


Fig.  48. — Skiagram  showing  size,  shape,  and  position  of  a  fragment  of  shell  which 
wotmded  the  second  part  of  the  riglit  subclavian  artery,  giving  rise  to  an  arterio- 
venous aneurysm.  The  resemblance  in  shape  of  the  fragment  to  a  deformed  bullet  is 
of  interest.      Under  the  care  of  Captain  Greaves. 


division,  a  simple  arterial  aneurysm  developed.  I  believe  this  latter 
to  be  a  far  from  uncommon  result  when  the  vein  is  completely 
severed  ;  retraction,  thrombosis,  and  spontaneous  closure  taking  place, 
while  the  arterial  wound  may  remain  patent.  Other  examples  have 
been  seen. 

Case  36. — ^Arterio-venous  aneurysm  of  junction  of  second  and  third 
parts  of  right  subclavian  artery.     Death  from  entry  of  air  into  veins. 

Pte.  W.  The  bullet  entered  over  the  junction  of  the  middle  and  inner 
thirds  of  the  clavicle,  and  emerged  at  the  upper  border  of  the  scapula 
behind. 


184      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

When  admitted  to  a  base  hospital  the  wounds  still  remained  open,  but 
they  rapidly  healed.  On  the  seventy-fifth  day  after  the  original  injury  there 
was  swellino-  and  pidsation  in  the  posterior  triangle  of  the  neck,  and  pulsa- 
tion of  the  small  bluish  scar  overlying  the  perforation  of  the  clavicle.  There 
was  a  well-marked  thrill  in  the  neck,  and  the  veins  in  the  posterior  triangle 
pulsated,  but  the  tumour  was  soft,  and  only  partly  obliterated  the  normal 
hollow  of  the  triangle.  A  loud  and  widely  conducted  machinery  murmur 
was  heard  on  auscultation. 

An  incision  was  made  along  the  inner  four-fifths  of  the  length  of  the 
clavicle,  with  an  angular  extension  running  upwards  along  the  anterior 
border  of  the  sternomastoid  tendon  for  two  inches. 

The  sternomastoid  muscle  was  divided  near  its  insertion  and  reflected 
upwards,  and  the  posterior  triangle  opened  up  in  its  whole  width.  The 
carotid  and  first  portion  of  the  subclavian  artery  were  now  bared  and 
cleared  from  the  vagus,  the  phrenic  nerve  was  identified,  and  a  provisional 
ligature  placed  around  the  first  part  of  the  subclavian  artery.  The  outer 
margin  and  half  the  breadth  of  the  anterior  scalene  muscle  were  divided, 
and  the  remainder  of  the  muscle  retracted  inwards  ;  by  this  step  a  second 
provisional  ligature  was  able  to  be  placed  on  the  artery  beyond  the  origin 
of  the  internal  mammary  artery  and  the  thyroid  axis. 

The  cords  of  the  brachial  plexus  needed  to  be  freed  from  the  surface 
of  the  dilated  vein.  The  vein  was  greatly  distended,  as  were  also  the 
external  jugular  and  some  other  branches  entering  it  ;  the  latter  were  tied 
off,  and  a  provisional  ligature  was  placed  on  the  axillary  vein.  The  outer 
end  of  the  third  part  of  the  artery  was  now  readily  secured,  and  a  pro\i- 
sional  ligature  placed  around  it. 

So  far  all  had  gone  as  regularly  as  clockwork,  and  every  precaution 
had  been  taken  except  to  close  provisionally  the  proximal  end  of  the 
subclavian  vein.  The  fact  that  this  was  adherent  and  continuous  with 
the  opening  in  the  clavicle  had  not  allowed  the  clavicle  to  be  divided,  and 
had  rendered  it  impracticable  to  draw  the  vein  fully  into  view.  An  attempt 
was  now  made  to  free  the  vein  from  its  connection  to  the  bone.  As  this  was 
done,  a  sound  of  air  entering  into  the  vein  was  heard.  The  sound  was  not 
loud,  neither  was  there  any  difficulty  in  controlling  the  haemorrhage  from 
the  opening  in  the  vein  ;  but  the  patient  became  suddenly  ill,  in  a  few 
seconds  the  heart's  action  failed,  and  although  he  continued  to  breathe, 
he  died  in  a  few  minutes  (G.  H.  M.). 

The  only  comment  to  be  made  on  this  case  is  that  the  accident 
might  have  been  avoided  had  a  provisional  ligature  been  placed  on 
the  innominate  vein.  The  amount  of  air  which  entered  must  have 
been  large,  for  the  exposed  internal  jugular  vein  became  bloodless, 
and  bubbles  of  air  could  be  seen  moving  in  it  in  association  with  the 
movements  of  resjDiration. 

Case  36a. — Arterio-venous  aneurysm  of  the  first  part  of  the  right  sub- 
clavian artery.  Ligature  of  the  innominate  artery.  Closure  of  the  orifice 
of  communication  by  ligature. 

Pte.  A.  Wounded  by  a  small  fi'agment  of  shell,  which  entered  about 
the  centre  of  the  anterior  border  of  the  right  trapezius  muscle,  and  was 
retained  in  a  position  unknown.  There  was  free  primarj-  bleeding,  con- 
trolled by  the  application  of  a  pad  and  dressing. 


VESSELS    OE    THE    NECK  185 

When  seen  fourteen  days  later,  there  was  wirlesi)reafl  subcutaneous 
eechymosis,  induration  in  the  line  of  the  wound  track,  and  f^encral  fullness 
of  the  posterior  triangle  of  the  neck.  A  rounded  localized  swelling  was  pal- 
pable beneath  the  lower  end  of  the  sternomastoid  muscle,  and  thrill  and  a 
continuous  bruit,  of  which  the  systolic  element  was  the  more  marked,  were 
present.  The  cardiac  apex  was  in  the  nipple  line,  and  the  sounds  could  be 
heard  distinct  from  the  bruit.  The  pulses  at  the  wrist  were  equal  in  volume 
and  force,  and  beat  100  to  the  minute.  The  venous  roar  was  audible  at  the 
wrist  on  auscultation. 

The  patient  was  kept  at  rest,  and  two  months  later  the  condition  was 
much  improved.  The  swelling  and  eechymosis  in  the  posterior  triangle 
had  disappeared,  and  a  local  sac  lying  beneath  the  sternomastoid  in  the  line 
of  the  common  carotid  artery,  and  extending  upwards  for  three  inches  above 
the  clavicle,  remained.  No  enlargement  of  the  superficial  veins  was  present, 
but  the  right  radial  pulse  was  a  little  weaker  than  the  left. 

On  the  seventieth  day  after  the  injury  an  operation  was  undertaken. 
An  angular  incision,  as  for  ligature  of  the  innominate  artery,  but  carried 
outwards  for  three-quarters  of  the  length  of  the  clavicle,  was  made,  and  the 
sternomastoid  muscle  was  divided  one  inch  above  its  insertion  and  reflected. 
This  procedure  exposed  a  thick-walled  sac,  apparently  emerging  from  the 
interval  between  the  longus  colli  and  the  anterior  scalene  muscles,  and 
extending  upwards  as  high  as  the  level  of  the  fourth  cervical  vertebra. 

The  carotid  artery  and  vagus  nerve  were  freed  from  the  inner  margin 
of  the  sac,  and  an  attempt  made  to  secure  the  root  of  the  first  part  of  the 
subclavian  artery  ;  this  proved  to  be  impracticable,  as  the  vessel  was  wide, 
and  implicated  in  the  wall  of  the  aneurysm  in  this  position.  Provisional 
ligatures  were  therefore  placed  upon  the  innominate  and  the  third  part  of 
the  subclavian  artery,  and  the  clearance  of  the  sac  proceeded  with.  The 
deep  aspect  of  the  sac  was  readily  raised  from  the  surface  of  the  anterior 
scalene  muscle,  which  was  widened  out,  and  on  its  surface  the  phrenic  nerve 
was  exposed.  On  attempting  to  free  the  inner  margin  of  the  sac,  a  wound 
was  made  into  it,  and  it  then  became  necessary  to  tighten  up  the  ligature 
on  the  innominate  artery.  The  opening  in  the  sac  was  controlled  by  the 
finger,  the  sac  freed  down  to  its  connection  with  the  artery  and  vein,  and  a 
ligature  thrown  around  the  junction  and  tied. 

The  wound  was  then  closed  ;  the  patient  had  lost  a  good  deal  of  blood 
during  the  latter  part  of  the  operation,  and  a  saline  infusion  was  given  in 
the  evening,  after  which  he  steadily  picked  up  (G.  H.  M.). 

The  following  day  the  patient  looked  pale,  and  was  somewhat  drowsy, 
but  he  had  a  pulse  of  104  of  good  volume,  and  said  "  he  felt  fine." 

On  the  evening  of  the  second  day  he  lost  power  in  the  left  upper 
extremity,  but  there  was  no  facial  weakness,  and  the  man  did  not 
appear  to  appreciate  that  his  arni  was  powerless.  On  the  fourth  day  no 
trace  of  the  paralysis  remained,  the  anaemia  was  much  less  marked,  and 
the  pulse  and  temperature  were  normal.  Stitches  were  removed  at  the  end 
of  eight   days. 

On  the  seventh  day  a  considerable  amount  of  lymph  escaped  from  the 
wound,  and  the  discharge  continued  for  some  five  days  ;  the  character  of 
this  discharge  suggested  injury  to  the  right  lymphatic  duct.  The  tempera- 
ture, which  had  never  risen  since  the  operation,  and  the  pulse,  remained 
normal  throughout,  and  steady  improvement  took  place.  At  no  time  was 
there  coldness  or  any  sign  of  trouble  in  the  right  upper  extremity. 

The  patient  made  an  excellent  recovery. 


LSd     arXSIIOT    IXJIRIES    TO    THE    BLOOD-VESSELS 

Case  'A7. — Arterial  haematoma  of  left  subclavian  artery.  Proximal 
ligature  of  the  first  portion  of  the  vessel.  Subsequent  extension  of  the 
aneurysm.     Death   from   exhaustion  later. 

Pte.  S.  A  fortnight  after  rec'C}>tioii  of  a  wound  by  a  bullet — which 
entered  the  chest  wall  over  the  sternum  just  to  the  inner  end  of  the  left 
clavicle,  and  emerged  behind  the  left  shoulder-joint — a  soft  pulsating  swelling, 
o\er  which  a  systolic  bruit  was  audible,  was  discovered. 

During-  the  next  six  days  the  swelling  increased  in  prominence  and 
extent,  filling  up  the  posterior  triangle,  and  o|)eration  became  necessary. 

Captain  Greaves  resected  the  inner  third  of  the  clavicle,  turned  it 
ujnvard  together  with  the  sternomastoid,  and  tied  the  first  portion  of  the 
subclavian  artery.  Eighteen  days  later  the  patient  was  transferred  to 
England . 

On  arrival,  the  aneurysm  was  active  and  continued  to  extend,  the 
wound  was  suppurating,  and  the  patient  ill.  It  was  not  considered  an 
operable  case,  and  the  patient  gradually  sank  and  died  from  exhaustion 
three  months  after  the  date  of  reception  of  the  injury. 

Case  38. — Arterial  haBmatoma  of  first  portion  of  right  subclavian 
artery.      Embolism  of  right  brachial   artery,      Gangrene  of  hand,     Death. 

Sergt.-Maj.  F.  Bullet  wound,  passing  from  over  inner  third  of  right 
clavicle  to  emerge  over  right  scapula.  A  week  later  pulsation  was  noted 
around  the  aperture  of  entry,  and  a  systolic  bruit  was  audible.  On  the 
eighth  day  the  hand  and  forearm  became  tense  and  swollen,  and  incipient 
gangrene  was  apparent.  The  radial  pulse  was  absent,  and  brachial  embolism 
was  diagnosed.  On  the  thirteenth  day  the  local  swelling  had  increased, 
but  the  general  condition  was  fair  ;    the  wound  of  exit  was  suppurating. 

On  the  twentieth  day,  an  attempt  to  deal  with  the  haematoma  was 
made.  The  clot  was  found  to  be  infected  ;  the  first  part  of  the  subclavian 
was  secured  with  great  difficulty,  and  the  patient  died  shortly  afterwards. 

Case  39. — Arterial  haematoma  of  third  portion  of  subclavian  artery. 
Local  ligature  of  the  vessel.     Gangrene  of  arm.     Amputation. 

Pte.  W.  Bullet  wound,  entering  just  below  clavicle,  and  emerging  at 
back  of  shoulder.  On  the  second  day  a  pulsating  tumour,  over  which  a 
systolic  murmur  was  audible,  was  detected.  Ten  days  later  the  tumour 
was  larger,  and  it  was  thought  advisable  to  operate.  An  injury  to  both 
artery  and  vein  was  discovered  at  the  point  of  junction  of  the  subclavian 
and  axillary.  Both  vessels  were  ligated  above  and  below  the  wounds  in 
their  walls. 

On  the  twelfth  day  the  hand  became  blue,  although  still  warm  ;  but 
with  the  swelling  a  rise  of  temperature  and  general  malaise  pointed  to 
septic  absorption,  and  on  the  thirteenth  day  the  arm  was  amputated  above 
the  elbow. 

The  post-operative  results  illustrate  almost  all  the  points  which 
require  attention  :  the  difficulty  of  successfully  dealing  with  secondary 
hiemorrhage  from  this  artery  in  an  infected  wound  ;  the  danger  of 
risking  an  operation  which  may  be  attended  by  free  bleeding  in  a 
patient  still  anaemic  from  primary  loss  of  blood  ;  the  futility  of  the 
operation  of  sim2:)le  proximal  ligatiu'e  in  the  case  of  a  large  trunk  giving 
off  branches  in  close  i)roximity  to  the  wounded  point  ;    the    danger 


VESSELS    OF    THE    NECK  387 

which  exists  at  the  root  of  the  neck  of  air  cnteriiif)'  the  ^reat  veins  ; 
lastly,  the  possibility  of  post-operative  embolism. 

The  death-rate  in  this  series  amounts  to  21-4  ])er  cent  of  all 
injuries,  and  85-7  per  cent  in  the  case  of  operations.  Jt  is  true  that 
in  four  of  the  cases  septic  infection  played  a  prominent  part,  but  none 
the  less  the  great  risk  Vv^hich  attends  these  operations  cannot  be  too 
strongly  impressed. 

In  two  cases  spontaneous  thrombosis  apjiears  to  have  effected 
a  cure  ;  while,  on  the  other  hand,  gangrene  resulted  from  arterial 
embolism  in  no  less  than  three  cases.  It  is  instructive  to  keep  in 
mind  the  fact  that  embolism  at  the  bifurcation  of  the  brachial  is  a 
comparatively  easy  accident  to  diagnose,  while  in  the  lower  limb 
this  is  not  the  case,  and,  moreover,  it  is  not  always  easy  to  detect 
an  embolus  even  on  post-mortem  examination.  These  cases,  and 
those  already  dealt  with  in  the  section  devoted  to  the  carotid  arteries, 
support  the  view  that  embolism  may  be  a  more  common  factor  in 
the  production  of  gangrene  of  the  limbs  than  is  generally  recognized. 

Mode  of  Operation. — In  any  case  of  subclavian  aneurysm,  the 
classical  incision  for  securing  the  third  portion  of  the  artery  needs  to 
be  considerably  elongated  towards  the  mid-line  ;  and  if  the  first  or 
second  portion  of  the  vessel  needs  to  be  dealt  with,  the  angular  inci- 
sion, following  the  anterior  border  of  the  sternomastoid  to  the  sterno- 
clavicular joint  and  then  carried  outwards  along  the  clavicle,  is  the 
most  suitable. 

The  superficial  structures  having  been  divided,  it  is  generally 
better  at  once  to  divide  the  sternomastoid  muscle,  about  one  inch 
above  its  clavicular  attachment.  The  area  to  be  dealt  with  is  thus 
fairly  well  exposed,  and  the-  first  part  of  the  subclavian  or  the 
innominate  trunk  can  be  readily  secured  should  it  prove  necessar}^ 
In  some  cases  it  becomes  then  advisable  to  divide  the  anterior  scalene 
muscle,  exercising  due  care  to  preserve  the  phrenic  nerve  intact. 

The  chief  difficulty  which  may  now  arise  lies  in  the  number  and 
size  of  the  branches  of  the  first  and  second  portions  of  the  artery, 
which  may  either  lead  directly  into  the  sac,  or  will  furnish  an  abiuidant 
supply  to  it  even  when  provisional  control  has  been  established  of  the 
innominate  or  the  first  part  of  the  subclavian,  and  the  third  part  of 
the  latter  vessel.  A  provisional  ligature  or  clamp  placed  upon  the 
innominate  is  in  itself  practically  useless  to  restrain  haemorrhage  from 
the  sac  if  this  be  opened,  and  the  same  holds  good  with  regard  to 
provisional  control  of  the  root  of  the  subclavian  artery.  This  was 
forcibly  demonstrated  in  Case  35,  in  which  instance  bleeding  from 
the  sac  seemed  to  be  almost  as  free  as  if  no  precaution  whatever  had 
been  taken.  It  is  clear  that  in  this  case  the  sternomastoid  and  the 
anterior  scalene  muscles  should  have  been  completely  divided  before 


188     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

the  sac  Avas  o})cned,  and  then  nmch  of  the  loss  of  blood  which  led  to 
a  fatal  issue  might  have  been  avoided. 

The  need  to  exercise  care  with  regard  to  the  recurrent  laryngeal 
nerve  and  the  thoracic  or  right  lymphatic  duct,  while  manipulating 
in  this  region,  may  be  mentioned  in  passing,  and  the  care  necessary 
in  dealing  with  the  veins. 

The  experience  gained  in  Case  36  shows  that  in  approaching 
arterio-venous  aneurysms  of  the  second  part  of  the  artery,  it  is  best 
to  place  a  provisional  control  on  the  innominate  vein  while  freeing 
the  first  part  of  the  subclavian,  shoidd  the  latter  have  acquired 
adhesions.  The  subclavian  vein  itself  is  usually  very  much  dilated, 
and  forms  the  major  part  of  the  tumour,  and  the  branches  are  also 
large.  The  latter  are  easily  secured  and  divided  between  ligatures, 
and  as  a  rule  this  precaution  should  be  taken  as  soon  as  the  branches 
are  fully  exposed. 

One  point  is  worthy  of  further  mention.  Is  it  better  to  divide 
the  clavicle  or  not  ?  In  the  majority  of  cases,  unless  the  junction  of 
the  subclavian  and  axillary  arteries  requires  to  be  exposed,  it  is  quite 
unnecessary  if  the  sternomastoid  be  divided  ;  section  of  the  bone 
increases  the  severity  of  the  operation,  and  entails  risk  of  injury  to 
the  aneurysmal  sac  or  the  veins.  I  think  the  procedure  should  be 
reserved  for  cases  of  exceptional  difficulty,  and  rarely  resorted  to. 

My  own  experience  leads  me  to  regard  operations  for  arterio- 
venous aneurysms  in  this  region  as  the  most  difficnlt  and  dangerous 
of  any  that  can  be  undertaken. 

Case  32a. — Intrathoracic  w^oxmd  of  left  subclavian  artery.  Haemothorax. 
Arterial  hsematoma.  Embolism  of  brachial  artery.  Gangrene  of  hand. 
Amputation.     {Omitted  from  p.  177.) 

Sergt.  W.  Wound  of  entry  in  left  posterior  triangle,  large  exit  near 
angle  of  left  scapula.  When  seen  at  the  end  of  the  M^eek,  a  large  htemo- 
thorax  had  developed,  and  a  loud  blowing  systolic  murmur  was  audible 
over  the  course  of  the  subclavian  artery.  No  pulsation  was  palpable.  A 
day  later,  the  hand  became  blue  and  cold,  pulsation  of  the  radial  artery 
was  extinguished,  but  not  that  of  the  brachial. 

The  patient  had  been  obliged  to  remain  three  days  in  the  trenches 
after  being  wounded,  and  he  was  suffei'ing  considerably.  He  was  anaemic, 
and  short  of  breath.  Considerable  ecchymosis  was  still  present  around  the 
wound  of  entry. 

In  view  of  the  man's  condition  an  arteriotomy  was  not  considered 
ad\dsable,  the  hand  became  gangrenous  in  the  anterior  third,  and  the  haemo- 
thorax suppurated. 

The  haemothorax  was  drained,  and  an  amputation  performed  through 
the  lower  third  of  the  forearm.  A  good  recovery  was  made,  and  the  man 
returned  home  in  good  condition,  but  the  ultimate  fate  of  the  haematoma 
is  unknown. 


189 


CHAPTER    IX. 

VESSELS     OF     THE     UPPER     EXTREMITY. 

AXILLARY     ARTERY. 

Fifty-four  cases  of  injury  to  this  artery  are  dealt  with  in  the 
series,  and  in  40  of  these  some  form  of  aneurysm  developed.  The 
incidence  on  the  two  sides  of  the  body  is  about  equal  :  of  48  of  the 
cases,  27  were  on  the  right  and  21  on  the  left  side  of  the  body.  15 
were  the  result  of  bullet  wounds,  and  39  of  injuries  by  fragments  of 
shells.  With  regard  to  distribution  over  the  length  of  the  vessel, 
amongst  52  injuries,  we  find  17  (32-6  per  cent)  were  of  the  first  part, 
14  (26-9  per  cent)  of  the  second  part,  and  21  (40-3  per  cent)  of  the 
third  part. 

It  will  be  observed  that  the  series  contains  a  very  large  propor- 
tion of  aneurysms.  This  depends  upon  two  conditions  :  first,  the 
wounds  of  the  soft  parts  were  for  the  most  part  of  a  comparatively 
slight  nature ;  and  secondly,  axillary  aneurysms,  excejDt  of  the 
third  part,  are  rarely  dealt  with  at  an  early  stage,  hence  the  great 
majority  of  them  reach  the  hospitals  on  the  lines  of  communication 
or  the  base.  For  the  same  reasons,  the  histories  show  that  primary 
ha.'morrhage  had  rarely  been  free,  and  secondary  haemorrhage  was 
not  a  frequent  complication  ;.  the  latter  occurred  in  13-3  per  cent  of 
all  the  cases,  and  in  only  one  led  to  a  fatal  issue. 

Special  conditions  exist  in  the  case  of  the  axillary  vessels  which 
influence  the  occurrence  of  either  primary  or  secondary  haemorrhage. 
First,  the  wounds  in  cases  which  reach  the  back  lines  are  usually  of 
the  slight  traversing  character,  or  those  in  which  the  missile  is  retained. 
In  only  three  instances  in  this  series  were  the  wounds  of  the 
surrounding  soft  parts  of  any  considerable  extent — which  points  to 
the  conclusion  that  large  wounds  of  the  axilla  accompanied  by  lesions 
of  the  great  vessels  are  often  fatal. 

The  second  condition  which  affects  the  occurrence  of  haemor- 
rhage is  the  disposition  of  large  nerve  trunks  parallel  to  and 
surrounding  the  vessel.  The  importance  of  this  anatomical  arrange- 
ment in  promoting  spontaneous  arrest  of  haemorrhage  from  large 
vessels  has  already  been  referred  to  in  the  general  section  (p.  27), 
as  also  its  influence  in  aiding  permanent  closure  of  wounds  of  the 
arteries.     This  feature  is  strikingly  illustrated  in  the  series  of  injuries 


190     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

under  consideration.  Thus,  amongst  the  54  cases,  we  find  no  less 
than  10  instances  in  which  permanent  obHteration  of  the  artery 
was  effected  spontaneously  :  in  all  without  the  occurrence  of  serious 
hncmorrhagc,  in  se\'eral  with  practically  none,  and  in  only  one  with 
evidence  of  the  formation  of  a  traumatic  aneiuysm — which  under- 
Avent  spontaneous  cm-e — taking  any  part  in  the  process.  It  is  difllcult 
to  say  what  grade  of  injury  w^as  present  in  these  lesions;  but  avc  know, 
from  experience  gained  in  operations  luidertaken  for  exploration  of 
the  nerves  in  the  axilla,  that  they  are  often  of  a  severe  character, 
since  considerable  lateral  wounds,  and  even  instances  of  complete 
severance,  have  been  met  with.  The  liability  of  the  axillary  artery 
to  injuries  of  a  contused  character  is  sufficiently  explained  b}^  a  glance 
at  its  relations  to  the  walls  of  the  cavity  in  which  it  lies  ;  we  \vei\Q 
the  humerus  on  the  outer  side,  the  margin  of  the  scapula  behind, 
the  ribs  on  the  inner  aspect,  and  the  clavicle  in  front,  all  furnishing 
opportunity  for  crushing  of  the  artery  between  the  missile  and  the 
bony  skeleton. 

I  think  it  must  be  assumed  that  spontaneous  obliteration  of  the 
axillary  vessels  is  perhaps  more  common  than  even  these  numbers 
suggest,  because  such  injuries  can  be  very  readily  overlooked  in  their 
early  stages  ;  in  fact,  attention  was  often  first  called  to  them,  not  on 
account  of  suspicion  raised  by  local  circulatory  signs,  but  by  the 
absence  of  the  radial  pulse  discovered  in  the  course  of  examination  of 
patients  in  whom  the  lesions  of  nerves  were  the  prominent  feature. 
In  connection  with  this  question  of  spontaneous  closure  of  wounds  of 
the  axillary  artery,  it  is  of  interest  to  note  that  in  two  cases,  dm-ing 
exploration  of  the  nerves  in  the  axilla,  a  vessel  large  enough  to  take 
in  great  measure  the  place  of  the  normal  artery  was  discovered.  It 
is  unfortunately  not  possible  to  say  whether  this  vessel  was  a  result 
of  canalization  of  the  temporarily  obliterated  trunk,  or  whether  it 
was  a  new  anastomotic  formation. 

The  second  sjoecial  characteristic  of  injuries  to  these  vessels  is 
the  co-existence  of  injury  to  the  nerve  trunks.  This  combination 
is  very  frequent,  and  in  view  of  the  close  association  of  the  vessels 
and  nerves,  it  appears  remarkable  that  the  latter  can  ever  escape 
simultaneous  injury.  Amongst  our  54  cases,  serious  nerve  com- 
plications are  noted  in  23  instances  (42-59  per  cent).  These  varied 
froin  complete  brachial  monoplegia  to  injury  to  a  single  nerve  or 
a  general  disturbance  of  sensory  function  ;  but,  as  will  be  seen 
later,  permanent  disability  is  a  very  frequent  consequence.  The 
musculo-spiral  and  the  median  nerves  are  those  most  prone  to  isolated 
injury,  the  former  as  a  result  of  its  position  directly  behind  the 
artery,  and  the  latter  as  a  result  of  its  mode  of  formation  by  two 
heads  which  surroimd  about  half  of  the  circumference  of  the  ^'cssel. 


VESSELS    OF    THE    UPPER    EXTREMITY  191 

Partial  lesions  of  the  median  are  not  nncommon  as  a  result  iA'  this 
anatomical  arrangement. 

The  third  speeial  feature  of  axillary  injuries  lies  in  the  frequency 
with  which  the  missile  which  injures  the  artery  enters  or  traverses 
the  thorax.  In  our  series  a  considerable  htemothorax  com])lieat((l 
the  arterial  injury  in  20  per  cent  of  all  the  cases.  This  complication 
is  one  to  be  specially  borne  in  mind  in  contemplating  early  surgical 
intervention  for  the  vascular  injury,  because  the  escape  of  a  large 
quantity  of  blood  into  the  thoracic  cavity  produces  an  anscmia  very 
unfavourable  to  the  performance  of  an  operation  which  may  involve 
the  occurrence  of  further  hirmorrhage. 

Signs  of  Injury  to  the  Axillary  Vessels. — The  signs  of  contu- 
sion and  obliteration  of  the  artery  may  be  shortly  summed  up  as 
consisting  in  extinction  of  the  radial  or  brachial  pidse,  absence  of 
any  local  vascular  bruits,  an  immediate  interference  with  the  motor 
power  of  the  limb  apparently  greater  than  the  severity  of  the  injury 
should  warrant,  an  exaggeration  of  the  results  of  injury  to  the 
nerves  ;  and  later,  an  unfavourable  influence  in  the  further  progress 
of  the  nerve  lesion. 

In  a  large  proportion  of  the  injuries  (40  out  of  54),  one  of  the 
forms  of  hsematoma  or  aneurysm  followed.  The  aneurysm  in  our 
series  was  purely  arterial  in  character  in  24  instances,  and  arterio- 
venous in  16.  In  9  of  the  latter  a  sac  was  certainly  present ;  in  7 
the  condition  was  one  of  aneurysmal  varix,  for  the  formation  of 
which  the  anatomical  arrangement  is  particularly  favourable. 

The  early  signs  in  these  cases  consist  in  a  considerable  degree 
of  general  swelling  of  the  limb,  combined  with  loss  of  power  and 
sensation,  which  latter  may  be  often  mvich  greater  than  the  actual 
severit}'^  of  the  nerve  lesion  would  seem  to  warrant.  The  loss  of 
function  may  be  mainly  due  to  nerve  concussion,  and  may  be  present 
when  no  serious  or  destructive  lesion  of  the  nerves  has  been  caused  ; 
in  such  cases  the  symptoms  clear  up  rapidly.  The  general  swelling 
of  the  limb  depends  upon  the  effusion  of  blood  into  the  axilla  and 
interference  with  the  venous  return.  The  radial  pulse  is  usually 
diminished  in  volume,  sometimes  absent  altogether. 

The  local  swelling  varies  in  extent  and  appearance  according  to 
which  portion  of  the  trunk  is  involved.  When  this  is  the  first 
portion,  the  blood  in  the  hfcmatoma  stage  usually  gives  rise  to  a 
more  or  less  ill-defined  flattened  swelling  obliterating  the  subclavicular 
fossa,  and  tends  to  spread  over  the  pectoral  muscle  and  towards  the 
median  line.     Widespread  ecchymosis  is  not  nncommon. 

When  the  lesion  is  of  the  second  part  of  the  artery,  the  resulting 
tumour  is  of  a  more  localized  character,  rounded  in  outline,  and  apt 
not  to  spread  beyond  the  confines  of  the  borders  of  the  pectoralis 


192      GUNSHOT    IXJUIUES    TO    THE    BLOOD-VESSELS 


Pig_  49. — Arterial  aneurysm  of  the  second  portion  of  the  left  axillary  artery. 
The  aperture  of  entry  of  the  bullet  is  seen  in  the  outer  part  of  the  deltoid  region,  small 
and  typical.  The  bullet  itself  was  retained  under  the  small  prominences,  due  to  the 
presence  of  subcutaneous  blood-clot,  seen  over  the  sternum  ;  note  also  the  ecchymosis 
in  this  region.  The  anterior  wall  of  the  axilla  projects  as  a  large  dome-like  cavity. 
The  wrist-drop,  due  to  injury  to  the  musculospiral  nerve,  is  well  sho\vn. 
care  of  Capt.  Fitzmaurice  Kelly. 


Under  the 


VESSELS    OF    THE    UPPER    EXTREMITY  193 

minor,  by  which  muscle  it  is  bound  down  and  confined.  When  the 
sac  reaches  any  considerable  size,  it  is  readily  palpable  in  the 
axilla. 

H^cmatomata  of  the  third  portion  arc  apt  to  be  more  irregular  in 
outline  ;  they  may  spread  along  the  vascular  cleft  into  the  arm  in  the 
line  of  the  main  vessel ;  or  the  extravasation  may  take  the  line  of 
some  of  the  branches,  most  commonly  that  of  either  the  circumflex 
or  the  subscapular.  If  the  circumflex,  great  subdeltoid  swelling  may 
develop  ;  if  the  subscapular,  the  effusion  travels  to  the  chest  Avail, 
and  may  collect  both  on  the  surface  and  beneath  the  scapula. 

Determination  as  to  whether  the  main  trunk  or  one  of  its  branches 
is  at  fault  may  be  a  matter  of  considerable  difficulty,  and  operative 
exploration  alone  may  clear  ujd  the  point.  The  subscapular  artery  is 
the  one  which  most  often  gives  rise  to  confusion.  I  have  twice  had 
occasion  to  ojoerate  in  such  cases.  In  one,  a  htematoma  in  connection 
with  the  second  part  of  the  artery  was  simulated,  as  the  effusion  was 
limited  at  the  lower  margin  of  the  peetoralis  minor  ;  further,  the 
radial  pulse  was  absent.  Exploration  showed  the  wound  to  be  of 
the  subscapular  branch  close  to  its  origin,  and  absence  of  the  radial 
pulse  proved  not  to  be  the  result  of  pressure,  but  of  obliteration  of 
the  main  trunk  following  contusion  of  its  walls.  In  the  second  case, 
the  effusion  had  followed  the  line  both  of  the  subscapular  artery  and 
that  taken  by  the  missile,  and  was  most  abundant  over  the  chest  wall 
and  around  the  scapula.  In  this  instance  a  pre-operative  correct 
diagnosis  was  made  ;  but  it  is  of  interest  to  note  that  this  patient  had 
complete  brachial  monoplegia,  which  suggested  a  lesion  of  the  main 
arterial  trunk  rather  than  of  a  branch.  The  subsequent  history  of 
this  patient  Avas  of  a  slow  general  recovery  of  nerve  function  from 
above  downwards,  suggesting  that  concussion  and  temporary  local 
pressure  were  responsible  for  the  monoplegia.  At  the  end  of  six 
months,  however,  recovery  was  very  far  from  complete. 

The  local  vascular  bruits  are  well  marked  ;  they  may  be  very 
widely  distributed  over  the  chest,  and  down  the  arm.  The  resonating 
factor  afforded  by  the  chest  allows  the  nnu-mur  to  be  heard  over  the 
whole  prascordial  region,  but  as  a  rule  the  sounds  of  the  heart  can  be 
heard  quite  distinct  from  the  aneurysmal  bruits.  In  four  eases  in 
our  series  a  distinct  systolic  murmur  replaced  the  normal  first  sound  ; 
two  of  these  cases  were  arterial  and  two  arterio-venous  in  nature. 
In  both  the  arterial  cases  the  bruit  was  heard  at  the  apex,  and  loudest 
at  the  base  of  the  left  ventricle.  In  the  arterio-venous  cases,  in  one 
the  systolic  murmur  was  audible  both  at  apex  and  base  of  the 
heart,  in  the  other  it  was  limited  to  the  base  and  the  apex  of  the 
left  ventricle,  as  is  the  rule  with  purely  arterial  lesions. 

In  one  patient,  an  axillary  varix  was  present  as  well  as  an  arterio- 
le 


194     GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

venous,  htrmatoma  of  the  inferior  tliyroid  artery,  the  latter  being'  at 
first  mistaken  for  a  earotid  injury. 

Prognosis  and  Treatment. — In  the  matter  of  ])rognosis,  injuries 
to  the  axillary  artery  have  an  unfavoiu-able  asj)eet  seeond  to  none 
in  the  body.  Quoad  vitce,  we  find  4  deaths  amongst  54  cases  (7-4 
per  cent).  Two  of  the  patients  died  from  the  combined  effects 
of  a  large  primary  haemorrhage  and  a  large  haematoma,  and  loss  of 
blood  consequent  upon  an  operation  undertaken  at  an  early  date  ; 


Fig.  50. — Skiagram  showing  fragment  of  shell  on  chest  wall,  and  smaller  fragments 
in  entry  end  of  wound  track,  which  gave  rise  to  the  development  of  an  aneurysmal 
varix  in  the  third  part  of  the  right  axillary  artery. 


one  of  these  accidents  might  perhaps  have  been  avoided  by  allowing 
a  longer  interval  to  elapse  before  dealing  with  the  ha^matoma  ;  but 
the  second  operation  was  undertaken  for  urgent  and  imperative  signs. 
One  patient  died  as  a  result  of  secondary  hjcmorrhage,  and  one  from 
acute  jDost-operative  tetanus. 

As  has  been  already  dwelt  upon,  spontaneous  arrest  of  htrmor- 
rhage  is  common  in  injuries  to  this  artery.  It  is  in  the  ultimate 
resvilts  attained  that  the  unfavourable  prognosis  asserts  itself. 

It  is  a  remarkable  fact  that  in  our  series  the  most  consistent  and 
persistent  loss  of  fvuietional  capacity  of  the  limb  was  often  seen  in 
those  instances  in  which  primary  spontaneous  thrombosis  had 
preserved  the  patient  from  most  of  the  earh^  dangers  of  a  wounded 


VESSELS    OF    THE    UPPER    EXTREMITY  195 

artery.  Amongst  the  ten  cases  here  recorded,  in  two  the  artery  is 
known  to  have  been  completely  severed  by  the  missile,  but  in  the 
remainder  it  is  impossible  to  say  what  grade  the  primary  injury 
reached,  or  what  extent  of  the  arterial  wall  was  destroyed.  Reasoning' 
from  the  evidence  offered  by  the  anatomical  findings  in  injuries  of 
this  class  to  the  carotid  arteries,  we  may  assume  that  in  some  instances 
the  lesion  was  not  of  an  extensive  character.  In  all  the  cases  the 
radial  pulse  was  primarily  obliterated,  and  in  the  majority  a  good 
radial  was  not  re-established  during  the  period  that  the  patients  were 
able  to  be  followed.  In  four  instances  both  the  radial  and  the  brachial 
pulses  were  impalpable,  and  in  these  the  primary  injury  must  be 
judged  to  have  been  extensive.  Only  in  one  of  the  10  cases  of 
traumatic  thrombosis  did  the  patient  escape  without  a  concomitant 
nerve  lesion,  and  in  this  instance  the  thrombosed  artery  lay  at  the 
bottom  of  a  large  open  wound  ;  this  vessel  eventually  gave  way 
secondarily,  giving  rise  to  a  secondary  haemorrhage  which  necessitated 
ligature.  Of  the  remaining  9  patients,  5  returned  to  England  with 
persistent  complete  brachial  monoplegia  ;  of  the  others,  one  proved 
to  have  suffered  division  of  the  median,  ulnar,  and  musculo-spiral 
nerves  ;  in  one  the  musculo-cutaneous  nerve  was  divided  and  the 
remaining  nerve  trunks  were  fixed  by  cicatricial  tissue  ;  in  one  the 
posterior  cord  and  its  branches  were  alone  affected  ;  and  in  one,  in 
whom  general  diminution  of  sensation  and  tingling  were  present,  the 
radial  pulse  returned  at  an  early  date.  I  regret  that  I  have  been 
unable  to  trace  these  patients  further,  but  general  experience  does 
not  warrant  the  expectation  that  any  great  improvement  took  place. 

Amongst  22  patients  in  whom  combined  arterial  and  nerve 
lesions  were  followed  by  the  formation  of  aneurysms,  the  results 
seem  little  superior.  In  9  of  these  the  radial  pulse  was  abolished, 
in  9  it  was  diminished  in  volume,  and  in  1  both  radial  and 
brachial  pulsation  was  imj)alpable.  In  only  one  case  of  axillary 
varix  was  the  blood-pressure  in  the  injured  limb  equal  to  that  in 
the  sound  one,  and  in  this  instance  the  lesion  was  the  result  of  a 
bayonet  stab,  and  not  a  gunshot  injury.  The  nerve  sj^mptoms  present 
in  these  cases  were  as  follows  :  complete  brachial  monoplegia,  7  ; 
signs  of  injury  to  median  and  ulnar  nerves,  3  ;  to  median  alone,  3  ; 
to  ulnar  alone,  2  ;  to  median,  musculo-spiral,  and  ulnar,  1  ;  to 
musculo-spiral,  musculo-cutaneous,  and  ulnar,  1 ;  general  anaesthesia, 
1  ;  anaesthesia  in  the  area  supplied  by  seventh  cervical  root,  1.  Only 
one  of  these  patients  recovered  sufficiently  to  retiu'n  to  active  service, 
the  great  majority  of  the  remainder  were  discharged  from  the  service 
as  permanently  unfit. 

It  is  not  only  from  the  point  of  contemporaneous  injury  to  the 
nerves  in  the  axilla  that  the  vascular  injuries  are  liable  to  be  followed 


196     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

by  iinsatisfactory  results.  From  the  purely  vascular  aspect  also, 
obliteration  of  the  artery  is  apt  to  be  followed  by  imperfect  results. 
It  is  rare  not  to  observe  a  cold  cyanotic  hand  after  ligature  of  this 
artery,  and  this  evidence  of  depressed  vitalit}^  may  persist  for 
considerable  periods  of  time.  Some  loss  of  volume  in  the  muscles  of 
the  limb  is  also  common,  as  much  as  one  inch  in  the  forearm  and  half 
an  inch  in  the  arm.  It  is  always  the  terminal  segments  of  the  limb 
which  suffer  the  more  severely. 

Arterio-venous  aneurysms  and  aneiuysmal  varices  often  give  rise 
to  little  change  during  the  period  the  modified  arterial  circulation  is 
not  interfered  with.  In  the  case  of  the  aneurysms  idtimate  operation 
is  necessary,  but  in  that  of  the  varices  it  is  best  avoided  if  possible. 
It  has  ahvays  been  known  that  these  conditions  give  rise  to  less  serious 
signs  of  venous  obstruction  in  the  upjDer  than  in  the  loAver  extremity  ; 
but  observation  of  a  large  number  of  cases  has  shown  that  venous 
obstruction  may  develop  more  frequently  than  has  been  supposed. 
I  have  seen  cases  which  clinically  exhibited  the  signs  of  a  pure  varix. 
in  which  the  condition  of  the  peripheral  veins  called  for  operation  ; 
in  one  of  these  a  tendency  to  enlargement  of  the  veins  also  existed 
in  the  uninjured  limb,  and  there  can  be  little  doubt  that  personal 
idiosyncrasy  in  this  respect  is  a  matter  that  must  not  be  lost  sight  of. 

Methods  of  Treatment  adopted  in  the  Series  of  Cases 
UNDER  Consideration. — A  considerable  variation  in  the  mode  in 
wdiich  the  cases  included  in  this  series  were  dealt  with  is  apparent. 
This  has  dejDcnded  on  an  imjaerfect  realization  in  the  early  days  of  the 
war  of  the  true  lines  which  should  be  followed  ;  but  these  have  now 
crystallized  out  in  definite  form  as  the  result  of  increased  experience. 

The  third  part  of  the  subclavian  artery  was  ligatured  in  continuity 
in  7  instances.  Twice  this  measure  was  adopted  as  the  sole  one. 
In  one  of  the  cases  the  operation  was  performed  to  check  primary 
haemorrhage  from  the  first  part  of  the  artery.  The  patient  was 
removed  to  a  hospital  on  the  line  of  communication  twenty-four  ho\irs 
later,  and  arrived  in  bad  condition.  The  whole  limb  was  swollen, 
pale,  and  cold,  and  suggested  a  state  of  incipient  gangrene.  With 
rest  and  care  during  the  next  seven  days  the  limb  improved,  and 
actual  gangrene  was  ultimately  limited  to  the  little  finger  and  the 
last  two  joints  of  the  thumb.  In  the  second  case  the  operation  was 
undertaken  as  a  measure  of  proximal  ligature  for  an  arterial  aneurysm 
of  the  third  part  of  the  axillary  artery.  The  aneinysm  was  eventually 
cured,  but  a  soft  fluctuating  blood  tumour,  surroimded  by  indurated 
tissues,  persisted  for  a  couple  of  months,  and  considerable  wasting  of 
the  arm  occurred. 

In  3  cases  ligature  of  the  third  part  of  the  subclavian  was 
combined  with  distal  ligature  of  the  third  part  of  the  axillary  artery. 


VESSELS    OF    THE    UFFER    EXTREMITY  197 

In  one  of  these  the  procedure  was  successful.  In  two  it  failed.  In 
one  of  the  latter  a  permanent  arterio-venous  communication  was 
left,  although  at  the  time  of  operation  the  decrease  effected  in  the 
blood-current  caused  a  temporary  disappearance  of  the  thrill  and 
murmur.  In  the  second,  persisting  haemorrhage  from  the  opened-up 
cavity  in  the  axilla  had  to  be  controlled  by  plugging,  the  wound 
being  sutured  secondarily  at  a  later  date. 

In  two  cases  the  subclavian  was  ligatured  for  the  treatment  of 
secondary  haemorrhage  occurring  after  local  ligature  of  the  axillary 
artery.     In  both  of  these  a  successful  result  was  attained. 

In  only  one  case  that  I  saw  had  the  wound  in  the  artery  been 
subjected  to  primary  sutiu'e.  This  operation  had  been  performed  by 
Major  Ozanne,  and  at  the  end  of  fourteen  days  pulsation  in  the 
brachial  artery  was  normal  in  volume.  It  was  vmfortunate  that  in 
this  instance  a  wound  of  the  forearm  had  necessitated  a  simultaneous 
ligature  of  the  radial  artery,  so  that  we  had  not  the  more  stringent 
test  of  the  pulse  at  the  wrist  to  go  by. 

In  an  arterial  aneurysm  of  23  months'  standing,  which  sprang 
by  a  broad  base  from  the  artery,  I  removed  the  greater  part  of  the 
adventitious  sac,  and  by  sewing  its  base  attempted  to  reconstruct 
the  artery.  This  operation  was  a  failure  from  the  ideal  point  of 
view,  although  a  good  result  was  obtained  as  far  as  curing  the 
aneurysm  and  preserving  a  useful  limb  was  concerned.  The  radial 
pulse  returned  in  this  case  in  eight  days.  In  one  instance  in  w^hich 
I  closed  the  communication  between  the  artery  and  vein,  by  suturing 
the  opening  from  the  laid-oiDcn  vein,  a  perfect  result  was  attained. 

I  have  only  the  record  of  one  case  of  wound  of  the  axillary  treated 
by  the  introduction  of  a  Tuffier's  tube.  It  was  not  a  success ;  the 
radial  pulse  disappeared  two  hours  after  insertion  of  the  tube ; 
the  latter  was  removed  at  the  end  of  forty-eight  hours,  and  the  two 
ends  of  the  vessel  were  closed  by  ligature.  Secondary  haemorrhage 
occurred  on  the  tenth  day,  and  the  artery  was  again  ligatured ;  but 
the  bleeding  recurred  at  the  end  of  two  days,  and  the  patient 
succumbed.  Infection  of  the  wound  was  responsible  for  this  fatality. 
Four  cases  were  treated  by  double  ligature  and  division  of 
the  intervening  part  of  the  artery  as  a  primary  measure,  and  all 
did  well;  the  same  may  be  said  of  five  out  of  eight  cases  in 
which  the  same  procedure  was  adopted  for  the  cure  of  aneurj^sms, 
with  the  reservation  that  has  been  foreshadowed  as  to  the  ultimate 
result  which  commonly  follows  occlusion   of  this  artery. 

The  causes  of  death  in  the  three  fatal  cases  have  already  been 
given  above. 

In  7  cases  the  artery  and  vein  were  tied  simultaneously,  and 
in  5  the  artery  alone.     The  only  case  of  gangrene  following  ligature 


198     GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

of  the  axillary  artery  was  included  in  the  latter  number  ;  but  it 
must  be  remarked  that  in  this  instance  one  of  the  heads  of  the 
median  nerve  had  been  divided,  and  injuries  to  this  nerve  are 
partieularl}^  dangerous  from  the  point  of  vicAv  of  the  nutrition  of 
the  limb. 


Fig.  '51. — External  surface  of  arterial  aneurysm  developed  in  connection  with 
the  second  portion  of  the  axillary  artery.  Tlie  arm  lias  been  placed  at  the  side. 
Captain  Santos, 


Injuries  to  this  vessel  which  require  operative  intervention 
should  always  be  dealt  with  locally.  The  same  procedure  is 
advisable  whether  the  first  or  second  portion  of  the  artery  needs 
to  be  tied. 


VESSELS    OF    TILE    UPPER    EXTREMITY 


199 


When  a  hrematoma  or  an  anenrysm  rcqnires  to  be  attacked,  the 
first  step  consists  in  the  appHcation  of  a  provisional  hgature  to  the 
third  part  of  the  subclavian  artery  to  ensure  absolute  control  of  the 
proximal  circulation.  This  preliminary  is  advisable  in  every  case, 
although  compression  of  the  subclavian  may  be  relied  upon  when  the 
aneiuysm  is  a  small  arterial  one  on  the  third  portion  of  the  axillary. 
Compression  is,  however,  a  poor  substitute  for  the  efficient  control 


H/ 


Fig.  52. — Wound  in  second  portion  of  axillary  artery  responsible  for  the  anem-ysm 
shown  in  Fig.  51.     Captain  Santos. 


and  the  confidence  engendered  by  a  provisional  ligature,  while  in 
arterio-venous  injuries  compression  may  be  an  actual  source  of 
difficulty  and  danger  by  augmenting  venous  ha>morrhage.  In  no 
other  situation  is  venous  haemorrhage  likely  to  be  more  free  and 
difficult  to  control  than  here  ;  and,  in  addition,  the  risk  of  entry  of 
air  into  the  veins  has  to  be  borne  in  mind.  Even  when  the  subclavian 
is  controlled,  the  nimiber  of  collateral  branches  springing  from  the 


200     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

axillary  artery  may  rurni.sh  sulliciciit  blood  to  render  it  dilliciilt  to 
keep  the  field  of  operation  free  for  sneh  a  procedure  as  suture  of 
the  wounded  trunk. 

The  second  step  consists  in  carrying  an  incision  from  the  centre 
of  the  clavicle  down  over  the  pectoral  region  to  the  level  of  the 
commencement  of  the  brachial  artery.  The  pectoral  muscles  are  then 
completely  divided,  in  order  to  gain  a  satisfactory  exposure  of  the 
vessels  in  their  Avhole  length,  and  ensure  the  safe  separation  of  the 
siu-rounding  nerve  trunks.  When  the  oi^eration  is  undertaken  after 
the  lapse  of  weeks  or  months,  and  persisting  signs  of  nerve  lesion  are 
present,  the  obvious  necessity  of  exploring  the  nerve  trunks  and 
freeing  them  from  adhesion,  or  possibly  reiDairing  damage,  adds  a 
second  reason  for  adopting  this  measure  beyond  that  of  avoiding 
haemorrhage  or  of  curing  an  aneurysm. 

The  pectoralis  major  is  divided  from  the  surface  ;  if  it  be  thought 
preferable,  the  pectoralis  minor  may  be  freed  by  blunt  dissection  from 
the  axillary  fascia  before  proceeding  to  divide  it.  A  cephalo-jugidar 
vein,  if  present,  should  be  preserved,  in  view  of  the  possibility  that 
the  axillary  vein  may  need  to  be  tied  later.  Branches  and  trunk 
of  the  acromio-thoracic  artery,  and  the  cephalic  vein,  should  also  be 
spared.  The  artery  is  now  exposed,  and  a  distal  ligature  is  applied 
as  a  provisional  measure.  In  recent  cases,  when  the  connective  tissue 
is  infiltrated  with  blood,  it  is  necessary  to  exercise  caution  that  the 
median  nerve  is  not  overlooked  and  damaged. 

The  actual  seat  of  damage  to  the  artery  can  now  be  investigated, 
and  if  the  operation  be  an  early  one,  the  vessel  will  be  either  sutured 
or  ligatured  as  may  seem  best.  If  the  artery  needs  to  be  ligatiu'cd, 
the  axillary  vein  should  also  be  occluded. 

If  a  false  aneurysm  of  any  standing  needs  to  be  dealt  with,  the 
Avail  of  the  sac  is  usually  readily  separable,  and  Avhen  it  has  been  freed, 
the  nature  of  its  communication  with  the  main  trunk  can  be  investi- 
gated. If  the  connection  be  broad,  suggesting  an  extensive  defect 
in  the  arterial  wall,  the  greater  part  of  the  sac  may  be  removed, 
retaining  a  portion,  which  may  be  sutiu-ed,  and  thus  the  viability  of 
the  artery  maintained.  If  the  connection  be  a  small  one,  the  whole 
sac  is  removed  and  the  defect  in  the  arterial  wall  sutured.  The 
latter,  is,  in  my  experience,  much  the  more  likely  to  prove  a  successful 
procediu'e. 

Prior  to  removal  of  the  sac,  it  is  often  convenient  to  place  either 
provisional  ligatures  or  clamps  on  the  artery  in  immediate  proximity 
to  the  aneurysm.  This  measure  has  the  double  advantage  of  not 
only  eliminating  a  number  of  branches  which  ma}^  supply  blood  and 
thus  render  the  operation  of  suture  less  easy,  but  it  also  shortens 
the  period  for  Avhieh  it  is  necessary  to  maintain  control  by  the  first 


VESSELS    OF    THE    UPPER    EXTREMITY  201 

provisional  ligature  on  the  third  \y<x,xt  ol'  the  siibelavian,  and  minimizes 
the  chance  of  damage  to  the  wall  of  that  vessel. 

A  word  of  special  caution  needs  to  be  uttered  with  regard  to  the 
process  of  removal  of  the  sac  ;  in  two  instances  in  my  own  operative 
experience  a  spread-out  head  of  the  median  nerve  has  formed  an 
integral  element  of  the  wall  of  the  aneurysm,  and  needed  to  be 
separated  with  very  great  care  ;  in  another  case  operated  upon  by 
my  colleague,  Captain  Z.  Mennell,  the  trunk  of  the  musculo-spiral 
nerve  was  similarly  disposed.  The  numerous  branches  of  the 
axillary  artery  form  another  troublesome  element  in  dealing  with 
these  aneurysms,  and  it  may  prove  necessary  temporarily  to  control 
one  or  more  of  them.  Obviously  they  should  never  be  divided, 
even  when  suture  is  chosen,  as  certainty  cannot  be  ensured  that 
thrombosis  may  not  convert  the  operation  into  one  of  occlusion. 

The  remaining  special  feature  of  axillary  operations  is  the  great 
difhculty  which  may  be  met  with  in  controlling  venous  haemorrhage 
when  the  first  part  of  the  axillary  vein  has  been  the  seat  of  injury. 
In  one  of  my  own  operations,  the  first  I  undertook,  I  unfortunatelj^ 
trusted  to  digital  compression  of  the  third  jDart  of  the  subclavian 
artery  for  control  of  the  arterial  circtilation  ;  the  artery  was  secured 
above  and  below  the  aneurysm  without  difficulty ;  but  the  vein, 
which  had  been  completely  severed,  had  retracted  beneath  the 
clavicle,  where  adhesions  had  formed  which  held  the  lumen  widely 
open  with  a  trumpet-shaped  mouth.  The  vein  was  eventually 
secured,  but  the  patient  died  the  sarhe  evening  as  the  result  of 
the  loss  of  blood  he  had  sustained  during  the  operation.  In  a 
second  case,  which  ended  more  happily,  the  artery  having  been 
ligatured,  persisting  venous  hai-morrhage  had  to  be  controlled  by 
the   insertion   of  a   plug. 

Any  further  details  in  the  performance  of  operations  on 
arterio-venous  aneurysms — the  manner  of  dealing  with  the  sac  or 
the  actual  communication  between  the  vessels — are  carried  out  on 
the  lines  laid  down  in  the  general  section  on  this  subject. 

BRACHIAL     ARTERY. 

In  spite  of  the  great  frequency  of  injuries  to  this  vessel, 
our  series  only  contains  43,  and  amongst  them  are  a  very  large 
proportion  of  accidents.  It  was,  indeed,  for  the  most  part  only 
what  may  be  called  serious  cases  that  came  under  my  special 
observation  ;  hence  this  section  offers  little  matter  for  statistical 
deduction,  although  it  affords  illustration  of  most  of  the  com- 
plications that  occur  in  the  course  of  treatment  of  injuries  to  the 
brachial   artery. 


202     GUNSHOT   INJURIES    TO    THE    BLOOD-VESSELS 

The  incidence  on  the  two  sides  of  the  body,  amongst  35  of 
the  cases,  is  —  right  20.  left  15.  Eight  injuries  were  to  the 
upper  third'  of  the  vessel,  8  to  the  middle  third,  and  15  to  the 
lower  third. 

The  proportion  of  cases  in  which  primary  haemorrhage  is  said 
to  have  been  free  is  comparatively  large,  12  out  of  43  (27-8  per 
cent).  Secondary  haemorrhage  occurred  in  6  (13-9  per  cent).  Nerve 
complications  occurred  in  10  cases  (23-25  per  cent)  ;  in  6  of  these 
the  median  was  the  trunk  injured,  in  2  the  museulo-sjDiral,  in  1  the 
ulnar,  and  in  2  all  three  nerves  were  involved. 

In  only  4  was  the  hximerus  fractured  ;  but  this  mmiber  gives 
little  idea  of  the  frequency  with  Avhieh  fractiu-es  of  the  humerus 
are  complicated  by  injury  to  the  artery.  Again,  only  one  was 
complicated  by  a  htcmothorax,  in  spite  of  the  notorious  frequency  of 
association  of  wounds  of  the  arm  and  the  chest. 

The  nmiiber  of  wounds  caused  by  bullet  and  fragments  of  shell 
is  practically  equal.  A  somewhat  large  proportion  of  extensive 
Avounds,  and  a  small  one  of  retained  missiles,  occurred. 

The  most  striking  feature  in  the  htcmatomata  and  aneiuysms  is 
the  great  preponderance  of  the  arterial  variety.  Thus,  of  25,  12 
were  pure  arterial  sacs,  only  1  an  arterio-venous  aneurysm,  and  5 
were  aneurysmal  varices.  The  explanation  is  no  doubt  found  in 
the  fact  that  a  wound  of  the  artery  of  an}'-  considerable  extent  is 
probably  generally  accompanied  by  complete  division  of  one  or 
other  of  the  venas  comites,  the  latter  being  comj^aratively  small  in 
consequence  of  the  large  size  of  the  more  distantly  situated  cephalic 
and  basilic  veins.  One  case  afforded  a  good  illustration  of  a  method 
by  which  early  establishment  of  an  arterio-venous  anastomosis  may 
be  prevented.  In  this  instance  the  small  fragment  of  shell  case  Avhich 
had  wounded  both  vessels  was  lodged  in  the  opening  in  the  vein,  and 
hence  only  an  arterial  h^ematoma  formed. 

The  rarity  with  which  an  arterial  murmur  is  transmitted  to  the 
heart  from  a  local  lesion  in  the  arm,  has  been  already  remarked 
(p.  54).  In  this  series  transmission  was  met  with  only  once,  and  the 
peculiarity  of  the  cardiac  murmur  which  was  heard  during  a  routine 
examination  of  the  chest  led  to  the  discovery  of  the  varix.  The 
latter  was  of  old  standing,  the  result  of  a  shot-gun  accident  six  years 
previously,  and  the  condition  had  not  given  rise  to  any  disability. 
The  case  also  affords  an  illustration  of  the  fact  that  transmission  of 
a  local  mui'miu'  may  be  a  permanent  phenomenon. 

In  5  cases  injury  to  the  brachial  artery  was  folloAved  by 
traumatic  thrombosis  and  obliteration ;  in  one  of  these  a  severe 
ischsemic  condition  of  the  limb  developed.  Probably  some  of  these 
cases  would  have  ^^assed  unnoticed  had  it  not  been  for  the  fact  that 


VESSELS    OF    THE    UFPER    EXTREMITY  203 

each  of  them  was  accompanied  by  signs  of  a  more  or  less  severe  lesion 
of  the  nerves.  In  two  cases  the  median  was  affected,  in  one  the 
uhiar,  in  one  the  median  and  musculo-siiiral,  and  in  one  there  was 
complete  loss  of  both  motion  and  sensation  in  the  limb  below  the 
wound,  the  track  of  which  passed  immediately  at  the  junction  of 
the  anterior  axillary  fold  with  the  arm.  The  patient  with  musculo- 
spiral  paralysis  is  the  only  one  I  have  been  able  to  trace  at  home  ; 
he  was  discharged  from  the  service  as  permanently  unfit  eleven  months 
after  the  injury.  The  conditions,  after  all,  are  very  like  those  which 
exist  in  the  case  of  the  axillary  artery.  In  a  few  cases,  not  in- 
cluded in  these  numbers,   I  have  seen  a  thrombosed  portion  of  the 


Fig.  53. — Raspberry-like  excrescence  on  brachial  artery  exposed  in  an  open  wound, 
on  fourth  day  after  injury,  illustrating  the  possible  occurrence  of  secondary  hajmorrhage 
or  the  development  of  an  aneurysm  as  the  result  of  incomplete  destruction  of  the 
arterial  wall. 

brachial  artery  resected.  Apart  from  the  common  association  of 
thrombosis  with  injury,  to  the  nerves,  the  condition  is  not  one  of 
great  importance. 

Nothing  special  needs  to  be  said  regarding  diagnosis  of  injuries 
to  this  artery  ;  but  an  interesting  ease  is  mentioned  in  the  next  section, 
in  which  a  varix  of  the  median  basilic  vein  at  the  bend  of  the  elbow, 
which  I  thought  to  be  in  communication  with  the  brachial,  proved  to 
be  connected  with  the  interosseous  artery  (p.  206). 

Prognosis  and  Treatment. — Apart  from  combined  injuries  of  the 
artery  and  the  nerves  of  the  arm,  wounds  of  the  brachial  artery, 
with  subsequent  obliteration  of  the  trunk,  would  seem  to  be  acci- 
dents of  small  importance.  In  the  few  cases  which  I  have  had  the 
opportunity    of   examining    months    after   the    injury,    however,    an 


204      GUNSHOT    fXJUlUKS    TO    THE    BTA)01)-VESSELS 

appreciable  loss  of  vohinic  of  the  limb  below  the  site  ol"  the  occlusion 
of  the  vessel,  and  a  lowering  of  the  distal  blood-pressure,  have  been 
])rescnt.  Yet  the  men  were  back  on  active  service,  not  complaining; 
and  mere  examination  of  the  affected  limb,  without  comparison  with 
the  uninjured  one,  would  have  warranted  the  surgeon  in  claiming  a 
perfect  result. 

Of  tlie  38  cases  in  which  the  artery  was  not  alread}^  occluded 
by  thrombosis,  24  were  treated  by  ligature,  and  6  by  suture  of  the 
artery  ;  the  remaining  8  cases  passed  from  my  observation  at  an 
early  stage. 

Ligature. — Of  the  24  cases  of  ligatiu'c,  17  were  of  the  artery 
alone,  and  7  of  both  artery  and  vein. 

Among  the  17  cases  of  ligature  of  the  artery,  there  were  6  cases 
of  gangrene,  and  1  case  occurred  among  the  7  in  which  the  artery  and 
vein  were  tied. 

Of  the  17  operations,  5  were  primary,  with  3  cases  of  gangrene  ; 
12  were  secondary,  also  with  3  cases  of  gangene. 

Of  the  three  cases  in  which  gangrene  followed  primary  ligature, 
in  one  the  haemorrhage  had  been  very  copious  and  ]:)allor  was  extreme, 
the  vessel  was  tied  in  an  open  wound  with  the  aid  of  local  aucTsthesia, 
arterial  gangrene  started  in  the  fingers,  followed  by  gas  gangrene, 
and  the  arm  was  amputated  ;  in  a  second,  the  patient  was  very  severely 
wounded,  lay  out  in  the  cold,  the  other  arm  and  one  leg  were  ampu- 
tated for  destructive  injuries,  and  the  ends  of  the  fingers  were  lost ; 
in  the  third  case,  arterial  gangrene  of  the  fingers  was  followed  by  gas 
gangrene,  and  amputation  was  performed. 

Of  the  three  cases  in  which  gangrene  followed  secondary  ligature, 
haemorrhage  was  the  indication  in  all.  In  two  of  them  the  median 
nerve  was  injured.  In  two,  digits  only  were  affected  ;  in  the  third 
the  gangrene  sjDread  up  the  anterior  surface  of  the  forearm.  Ampu- 
tation  was   successfully  performed  in  each. 

In  the  only  case  of  gangrene  following  ligature  of  artery  and  vein, 
the  gangrene  extended  only  to  the  base  of  the  terminal  phalanges. 
Suppuration  of  the  forearm  afterwards  necessitated  amputation. 

The  indications  for  ligature  of  the  artery  alone  were  :  primary 
hirmorrhage  5,  secondary  htemorrhage  5,  arterial  htcmatoma  6, 
aneurysmal  varix  1  (a  failure).  The  indications  for  ligature  of  artery 
and  vein  were  in  all  cases  arterial  hrematomata. 

As  to  the  permanent  results,  I  have  only  knowledge  of  two,  and 
these  returned  to   duty. 

Suture. — In  6  cases  wounds  of  the  vessel  were  sutured.  In 
3  the  wound  was  resected  on  accoimt  of  its  extent,  and  end-to-end 
union  was  established.  The  first,  a  primary  operation,  failed,  as  the 
union  gave  way  on  the  tenth  day  and  the  vessel  required  to  be  liga- 


VESSELS    OF    THE    UPPER    EXTREMrPY  205 

tured  ;  the  suture  had  torn  from  the  distal  end  of  the  vessel.  In 
the  second,  the  operation  was  performed  on  the  nineteenth  day  ;  the 
pulse  was  maintained  ;  on  the  fourth  day  the  blood-pressure  in  the 
periphery  was  90  mm.,  against  125  mm.  on  the  somid  side  ;  on  the 
twenty-fourth  day  it  was  127  mm.,  against  140  mm. ;  the  man  is 
now  working  in  a  colliery.  In  the  third,  the  operation  was  performed 
on  the  twenty-second  day  ;  the  radial  pulse  failed  at  the  end  of 
forty-eight  hours,  and  returned  on  the  fifth  day,  on  which  date  the 
peripheral  blood-pressure  was  80  mm.,  against  127  mm.  in  the  sound 
limb  ;    the  patient  has  returned  to  Australia. 

In  3  cases  lateral  suture  was  performed.  In  the  first  a  long 
vertical  slit  in  the  artery  was  closed  in  the  horizontal  line ;  the 
radial  pidse  was  suppressed  at  the  end  of  twenty-four  hours,  and 
returned  in  seven  days  ;  the  man  rejoined  his  regiment  four  months 
later.  In  the  second,  a  lateral  suture  of  half  the  circumference  of  the 
artery  was  performed  on  the  fourteenth  day  by  Captain  Greaves  ; 
the  radial  pulse  was  maintained,  and  on  the  tenth  day  the  peri- 
pheral blood-pressure  was  equal  to  that  of  the  sound  limb.  In  the 
third,  a  varix  for  which  proximal  ligature  had  been  performed 
unsuccessfully  twenty-three  months  previously,  a  type  operation 
was  performed  by  Mr.  Edred  Corner,  but  the  vein  was  utilized  to 
supplement  the  arterial  suture  ;  the  radial  pulse  (possibly  already  an 
anastomotic  one)  was  retained,  but  three  weeks  later  the  peripheral 
blood-pressure  was  only  60  mm.,  against  135  mm.  on  the  sound  side. 

This  small  series  affords  one  absolute  failure,  but  it  must  be  borne 
in  mind  that  the  giving  way  of  the  line  of  union  followed  transport 
and  removal  of  the  splint.  There  were  two  good  results,  one  of  them 
ideal.  In  three  cases  the  results  were  not  materially  better  than 
those  of  ligature. 

A  word  remains  to  be  said  regarding  the  oeeiuTence  of  such  a 
large  proportion  of  gangrene  after  ligature.  There  are  two  or  three 
special  reasons  to  explain  this.  In  the  first  place,  unfortunately 
the  arm  is  an  easy  place  to  apply  a  tight  tourniquet.  In  several  of  the 
cases  this  had  been  done,  and  in  one  it  w^as  probabh^  responsible  for 
the  subsequent  gangrene.  In  one  case  exposure  to  cold  and  exhaus- 
tion was  at  any  rate  ancillary,  if  not  the  sole  cause.  In  two  cases 
secondary  gas  gangrene  developed,  a  sequence  which  has  always  been 
possible,  and  is  greatly  favoured  by  occlusion  of  a  main  trunk.  In 
both  of  these  patients,  however,  antemic  gangrene  of  the  fingers 
developed  prior  to  and  independently  of  the  extending  infective 
gangrene. 

It  may  be  worth  mentioning  that  high  division  of  the  brachial 
artery  was  seen  several  times.  In  one  case  in  which  it  had  been  hoped 
to  repair  the  lower  part  of  the  vessel,  and  in  Avhich  resort  had  to  be 


206     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

had  to  lioaturc,  it  Avas  noted  that  the  radial  pulse  was  unaffected. 
Had  the  operation  of  suture  been  practicable,  the  condition  would 
not  have  been  suspected,  and  an  ideal  result  would  have  been  claimed 
Avhicli  might  not  have  been  really  justified. 

In  three  of  the  cases  of  gangrene  the  median  nerve  had  suffered 
injvuy,  and  there  is  no  doubt  whatever  that  damage  to  this  nerve 
is  a  very  important  contributory  cause  to  the  occurrence  of  the 
accident. 

It  seems  unnecessary  to  give  any  detailed  description  of  the 
appropriate  methods  of  operation.  A  free  incision,  care  of  the  nerve 
trunks,  and  sufficient  mobilization  of  the  artery  without  division  of 
branches,  if  either  suture  or  ligature  be  contemplated,  are  the  only 
points  of  importance.  The  artery  is  a  very  convenient  one  for  either 
resection  and  end-to-end  junction  or  lateral  suture,  and  in  suitable 
cases  repair  should  be  preferred  to  occlusion.  Arterial  hrcmatomata 
or  arterio-venous  aneurysms  should  alwaj^s  be  operated  upon.  In 
cases  of  aneurysmal  varix,  the  surgeon  exercises  his  own  judgement, 
but  in  many  cases  there  are  no  signs  or  symptoms  which  warrant 
interference. 

VESSELS    OF    THE    FOREARM. 

Wounds  of  the  radial  or  ulnar  arteries  are  common,  but  they  do 
not  call  for  any  special  description  ;  the  pulse  at  the  wrist  is  rapidly 
re-established  after  a  wound  of  one  of  the  vessels,  and  interference 
with  the  nutrition  of  the  hand  is  usually  negligible. 

In  consequence  of  the  small  calibre  of  the  vessels,  complete 
severances  of  continuity  are  common  ;  while  for  the  establishment  of 
an  aneurysm  or  arterio-venous  communication,  either  the  injury  must 
be  slight  or  the  missile  very  small.  Traimiatic  aneurysms  on  these 
vessels,  therefore,  are  not  common. 

It  is  rather  interesting  to  note  how  loud  arterio-venous  murmurs 
may  be  in  consequence  of  the  superficial  situation  of  the  arteries  in 
the  lower  half  of  the  forearm,  and  for  the  same  reason  the  murnnu's 
may  be  very  much  changed  in  character  by  pressure  exerted  by  the 
bell  of  the  stethoscope. 

One  case  may  be  quoted  to  illustrate  the  difficulty  which  often 
exists  in  locating  the  actual  position  of  an  arterio-venous  communica- 
tion and  determining  the  vessels  involved.  The  womid  was  caused 
by  a  fragment  of  a  bomb  which  entered  exactly  in  the  centre  of  the 
elbow-crease  of  the  right  arm.  An  aneurysmal  varix  resulted,  and  was 
disregarded  until  a  wound  of  the  elbow- joint  was  received  nearly  two 
years  later.  The  elbow  became  ankylosed  at  a  right  angle,  and  the 
limitation  of  movement  may  have  been  responsible  for  enlargement 
of  the  varix,  in  so  far  as  it  interfered  with  the  normal  mechanism  of 


VESSELS    OF    THE    UPPER    EXTREMITY  207 

the  venous  circulation.  A  varix  the  size  of  a  pigeon's  egg  had 
developed  in  the  median  basilic  vein  ;  this  pulsated  freely,  and  I 
assiuned  that  a  direct  comminiication  with  the  brachial  artery  as  it 
lay  beneath  the  bicipital  fascia  was  present.  On  dissection,  the  varix 
was  readily  lifted  from  the  surface  of  the  brachial,  and  it  became 
evident  that  the  pulsation  and  thrill  were  both  conducted  from  a 
vein  of  the  forearm,  probably  the  deep  median.  This  vein  and  the 
interosseous  branch  of  the  ulnar  artery  were  ligatured,  and  pulsation 
and  thrill  were  permanently  abolished. 

Quadruple  ligature  of  the  vessels  and  excision  of  the  sac  is  the 
form  of  ojaeration  applicable  to  arterio-venous  aneurysms,  and 
excision  and  double  ligature  of  the  artery  for  the  arterial  variety. 


208 


CHAPTER   X. 
VESSELS     OF     THE     LOWER     EXTREMITY. 

FEMORAL     VESSELS. 

The  femoral  vessels  afford  the  largest  series  of  injuries,  170  in  all. 
The  incidence  on  the  two  sides  of  the  body  was  about  equal :  of 
117  of  the  cases,  56  were  injuries  to  the  right  and  61  injuries  to 
the  left  thigh.  A  very  great  majority  of  the  lesions  Avere  caused  by 
fragments  of  shells,  although  during  the  first  months  of  the  war  this 
Avas  not  the  case,  and  bullet  injuries  Avere  frequent.  It  is  notcAVorthy 
that  increase  in  the  23roportional  nimiber  of  arterio-A^enous  to  arterial 
aneurysms  corresponded  in  date  Avith  the  change  in  the  nature  of  the 
missile  causing  the  Avounds  of  the  A'^essels. 

A  history  of  profuse  primary  ha-morrhage  Avas  rare  amongst  the 
patients  Avho  reached  the  hospitals  on  the  lines  of  communication  ; 
it  is  only  noted  to  have  occurred  in  18  out  of  150.  The  same  remark 
holds  good  amongst  the  small  number  of  cases  treated  at  the  casualty 
clearing  stations  Avhich  are  quoted  here. 

Amongst  75  cases  in  AA^iich  the  nature  of  the  AA'ound  of  the  soft 
parts  is  specially  recorded,  in  43  it  consisted  of  a  limited  through- 
and-through  track  ;  in  18  the  missile  A\^as  retained  ;  and  in  onl}^  14 
Avas  the  AA^ound  large  and  extensiA'cly  lacerated.  Com2olications  are 
not  a  striking  feature.  Thus,  in  only  15  Avas  a  fracture  of  the  femiu- 
present.  It  may,  hoAACA^er,  be  remarked  that  a  large  addition  to 
this  number  Avould  be  probable  Avere  the  cases  of  fracture  of  the 
femur  sifted  for  arterial  complications.  Associated  injury  to  nerves 
Avas  also  rare  ;  perhaps  the  most  common  Avas  injm-y  to  the  great 
sciatic  trmik  in  Avound  tracks  passing  from  before  backAA-ards.  It 
AA'as  surprising  to  notice,  in  the  coiu'se  of  operations  on  the  superficial 
femoral  artery,  hoAv  rarely  either  the  long  saphenous  or  the  nerAC 
to  the  A'astus  intcrnus  had  been  injiu'cd. 

Thrombosis. — In  20  cases  there  Avas  reason  to  belicA'c  that 
thrombosis  had  ensued  after  the  infliction  of  either  contusion  or 
Avound  of  the  vessel ;  and  as  this  sequence  is  of  A'crA^  considerable 
interest,  as  bearing  not  only  upon  the  question  of  spontaneous  arrest 
of  hfcmorrhagc,  but  also  on  that  of  definite  spontaneous  cm-e  of 
Avoundcd  arteries,  the  small  scries  is  AvorthA^  of  anah^sis.     The  cA-idencc 


VESSELS    OF    TILE    LOWER    EXTREMITY  209 

rests  in  part  on  clinical  investigation,   in  j^art  on   ocular  pnxjf  by 
direct  observation  in  woinids. 

It  will  be  well  to  deal  first  with  the  instances  in  which  the  dia- 
gnosis   dej^ended    npon    clinical    investigation    alone.      In    seven    the 
evidence   consisted   almost   solely   of  the    disappearance   of    a    local 
arterial  bruit,  or  the  combination  of  this  with  a  transmitted  niiirnnir 
t  o  the  heart. 

Case  40. — An  officer  received  a  small  through-and-through  wound  of 
both  thighs.  It  was  originally  thought  that  one  femur  had  been  fractured, 
but  this  assumption  was  negatived  by  x-ray  examination.  Four  days  later, 
examination  of  the  heart  showed  the  apex  to  lie  in  the  nipple  line,  the  pulse 
to  vary  from  80  to  90,  and  auscultation  disclosed  a  loud  bruit  audible  over 
the  base  of  the  heart.  This  murmur  had  been  likened  to  that  dependent  on 
pericardial  friction,  but  the  bruit  really  consisted  of  the  typical  loud  venous 
roar,  with  systolic  exacerbations.  The  first  sound  was  replaced  by  the 
systolic  bruit,  while  the  second  was  loud,  pronounced,  and  quite  clear. 

On  examination  of  the  thigh,  eeehymosis  was  seen  over  the  triangle  of 
Scarpa,  but  there  was  little  or  no  swelling,  and  neither  thrill  nor  pulsation 
could  be  detected.  The  posterior  tibial  pulse  was  present.  On  ausculta- 
tion, a  loud  venous  roar  and  a  comparatively  soft  systolic  bruit  were  audible 
over  the  commencement  of  the  superficial  femoral  artery,  and  conducted  in 
both  directions.  The  presence  of  an  arterio-venous  communication  was 
therefore  demonstrated,  and  the  presence  of  both  sets  of  murmurs  was 
corroborated  by  at  least  three  experienced  auseultators. 

Fourteen  days  later  I  saw  this  patient  in  London  ;  the  local  murmur 
had  then  completely  disappeared,  no  pulsation  or  thrill  could  be  detected, 
and  the  tibial  pulses  were  present  ;  but  a  faint  systolic  bruit  persisted  at  the 
apex  of  the  heart  for  a  few  days  longer.  The  patient  was  kept  at  rest  in 
bed  for  a  further  period  of  three  weeks,  and  then  allowed  to  move  about  ; 
no  recurrence  of  any  of  the  signs  took  place. 

Case  41. — A  sepoy,  with  a  fracture  of  the  femur  just  below  the  tro- 
chanters, was  found  to  have  a  systolic  bruit  audible  over  the  course  of  the 
femoral  artery  just  below  Poupart's  ligament,  and  no  pulsation  could  be 
detected  in  the  vessel.  This  bruit  persisted  for  three  weeks,  but  two  months 
later  it  had  disappeared,  and  both  the  tibial  pulses  were  palpable. 

Case  42. — Pte.  W.  A  through-and-through  track  traversed  the  upper 
third  of  the  thigh  ;  no  pulsation  was  palpable  in  the  femoral  artery,  and  a 
local  systolic  bruit  was  audible.  The  dorsalis  pedis  artery  was  pidsating, 
but  not  the  posterior  tibial.  Seventeen  days  later  the  bruit  had  disappeared, 
and  the  oedema  of  the  foot,  present  at  the  time  of  the  first  examination, 
had  subsided. 

Case  43. — Pte.  R.  A  through-and-through  wound  traversed  the  thigh 
just  below  its  centre.  A  tense  pulsating  swelling  was  present  in  the 
adductor  region.  On  the  fourteenth  day  all  pulsation  had  disappeared,  a 
soft  venous  bruit  was  audible,  and  the  tibial  pulses  were  present.  On  the 
twentieth  day  neither  pulsation  nor  bruit  could  be  detected. 

Case  44. — Pte.  S.  Small  wound  of  left  thigh.  After  being  dressed. 
the  patient  was  sent  back  to  the  trenches.  Five  days  later  a  small  tense 
swelling  was  detected  over  the  junction  of  the  middle  and  lower  thirds  of 

14 


210     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

the  superficial  femoral  artery,  and  a  local  systolic  bruit  was  audible  at 
this  spot.  Two  days  later  the  bruit  had  disjvpiJeared,  and  the  patient  was 
shortly  afterwards  evacuated  to  England. 

Case  45. — Pte.  T.  Through-and-through  track  in  thigh,  and  a  fracture 
of  the  femur.  The  thigh  was  much  swollen,  but  the  jjostcrior  tibial  pulse 
was  })resent.  A  systolic  bruit  was  audible  at  the  apex  of  the  heart.  Sixteen 
days  later  the  swelling  of  the  thigh  had  much  diminished,  and  the  cardiac 
bruit  had  disappeared. 

Case  46. — Pte.  W.  Shell  wound  of  thigh.  The  wound  bled  freely 
primarily,  and  the  patient  controlled  the  haemorrhage  by  tying  a  tourniquet 
around  the  limb.  The  man  lay  out  for  two  days,  and  when  brought  in 
to  the  casualty  clearing  station  an  arterio-venous  communication  was 
diagnosed.  A  week  later  a  systolic  bruit  was  still  audible  at  the  cardiac 
apex,  but  the  local  signs  had  disappeared. 

The  above  7  cases  might  perha]:)s  be  more  accurately  classed 
under  the  heading  '  spontaneous  healing, '  but  local  thrombosis  is 
none  the  less  the  necessary  part  of  the  process  of  cure.  It  Avill  be 
noted  that,  in  the  last  two,  the  presence  of  a  cardiac  bruit  was  relied 
ujDon  as  evidence  of  a  local  lesion  of  the  vessels.  This  sign  has  been 
so  often  substantiated  in  my  own  experience  b}^  the  discover}^  of  a 
definite  local  lesion  that  I  consider  that  its  importance  should  ne^■er 
be  discounted. 

In  the  remaining  13  cases,  ocular  demonstration  of  complete 
thrombosis  of  the  artery  was  afforded  ;  in  5  it  was  seen  and  palpated 
in  the  floor  of  a  large  open  wound,  in  7  it  was  seen  during  the  perform- 
ance of  operations,  while  in  the  thirteenth  case  a  contused  artery, 
still  viable,  was  associated  with  a  completely  divided  vein.  In  two 
instances  a  wounded  vein  was  associated  with  a  thrombosed  artery, 
and  in  two  a  wounded  artery  was  associated  with  a  thrombosed  vein. 

Putting  aside  the  significance  of  thrombosis  as  an  element  in 
the  process  of  spontaneous  ciu'e,  its  chief  interest  lies  in  its  relation 
to  the  occurrence  of  secondary  haemorrhage,  to  its  importance  as 
a  stage  in  the  develoiament  of  secondary  traimiatic  anein-ysms,  and 
to  the  risk  of  embolism  and  its  attendant  consequences. 

Secondary  ha-morrhage  occurred  in  5  out  of  the  13  cases  under 
consideration,  on  the  fourth,  sixth,  eighth,  tenth,  and  fourteenth  days 
respectively.  It  is  obvious  that  septic  infection  is  as  a  rule  responsible 
for  the  accident,  and  in  one  of  the  five  patients  gas  gangrene  was 
the  actual  cause  ;  but,  as  has  been  repeatedly  pointed  out,  secondary 
hirmorrhage  may  result  from  the  separation  of  an  aseptic  slough. 
Experience  has  therefore  amply  demonstrated  the  wisdom  of  excising 
the  thrombosed  portion  of  any  artery  exposed  in  the  original  wound 
or  met  with  during  the  performance  of  an  operation.  The  difficulty 
of  correctly  estimating  the  actual  degree  of  damage  to  the  w^all  of 
the  vessel  by  external  inspection  may  be  great  or  insuperable  ;   but 


VESSELS    OF    THE    LOWER    EXTREMrTY 


211 


in  some  cases  it  may  be  readily  gauged.  Thus,  an  artery  may  look  as 
if  "  it  had  been  rubbed  with  a  coarse  rasp  "  ;  while  in  an  instance  sucJi 
as  that  figiu'ed  on  p.  10  {Plate  I),  the  small  dark  spot  seen  on  the  outer 
surface  of  the  vessel  gave  little  indication  of  either  the  degree  or 
extent  of  the  lesion. 

In  this  small  series  two  instances  are  included  in  which  a  local 
bulging  of  a  partially  damaged  wall  was  seen  ;  in  one  the  inner  coat 
was  bulging  through  a  defect  in  the  adventitia  like  the  inner  tube  of 
a  bicycle  tyre  bulging  through  a  hole  in  the  cover  (Lieut. -Colonel 
Cowell)  ;  in  the  second  {Fig.  6,  p.  14)  a  small  local  bulge  due  to  a 
defect  in  the  inner  coat  at  the  upper  limit  of  a  vertical  wound  was 
exposed  during  an  operation  for  suture  of  the  wound  in  the  artery. 
The  prognostic  significance  of  the  latter  observation,  made  at  a  period 
of  four  months  after  infliction  of  the  injury,  is  perhaps  not  great ; 
but  the  former  illustrates  well  the  condition  which  may  precede  the 
occurrence  of  either  secondary  haemorrhage  or  a  tardily  developing 
traumatic  aneurysm. 

Secondary  embolism  was  met  with  only  once  in  the  series  ;  the 
embolus  was  arrested  at  the  point  of  bifurcation  of  the  popliteal 
artery,  and  occasioned  gangrene  of  the  foot  and  leg. 

Nature  and  Distribution  of  Wounds  of  tlie  Femoral  Vessels. — Little 
need  be  said  specially  as  to  the  nature  of  the  wounds  in  the  walls  of 
these  vessels.  In  the  great  majority  of  the  instances  which  come  on 
to  the  operating  table,  these  are  of 
the  lateral  variety.  Amongst  22 
cases  in  which  primary  ligature  was 
performed,  14  lateral  wounds,  3 
perforations,  and  5  complete  sever- 
ances were  met  with.  In  45  eases 
in  which  operations  were  under- 
taken at  a  later  date,  31  lateral 
wounds,  7  extensive  lateral  wounds 
approximating  complete  severances, 
5  complete  severances,  and  2  per- 
forations were  found.  Perforations 
have  become  rarer  with  the  increase 
in  frequency  of  wounds  caused  by 
shells.  These,  too,  are  apt  to  be 
followed  by  the  development  of 
aneurysmal  varices.  A  number  of 
the  latter  would  have  escaped 
notice  as  far  as  this  series  is  con- 
cerned, since  it  deals  mainl}^  with  cases  in  Ayhich  earl}'  operations 
were  undertaken. 


Fig.  54. — Wound  of  superficial  and 
dee2D  femoral  arteries,  the  profunda  dis- 
placed inwards  ;  the  opening  into  the 
sac  behind  the  vessels  is  seen,  margin- 
ated  below  by  the  insertion  of  the 
adductors. 


212      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

or  150  cases,  tlic  wounds  of  the  femoral  vessels  were  distributed  as 
follows  :  ii])])er  third.  45  ;  middle  third,  65  ;  lower  third.  40.  Certain 
portions  of  the  arteries  are  specially  liable  to  serious  injury.  Thus, 
the  common  femoral  is  fixed  at  its  origin,  and  again  by  the  profunda 
branch,  which  ties  it  fh-mly  in  position.  At  the  latter  sjDot  w^ounds 
are  frequent,  and  a^it  to  be  severe.  In  three  cases  I  saw  the  deep 
femoral  completely  cut  off  from  the  main  trunk,  and  in  several  it 
was  wounded  in  combination  with  the  superficial  branch.  A  good 
example  is  furnished  by  Fig.  54.  During  its  coiu'se  through  Hunter's 
canal  the  sujoerficial  femoral  is  firmly  supported  throughout  by  muscles 
and  the  aponeiu'otic  roof  of  the  canal,  so  that  the  vessel  can  scarcely 
escape  a  missile  traversing  its  course.  The  most  dangerous  spot  of 
all  is  the  extreme  lower  end  where  the  artery  lies  in  the  so-called 
adductor  canal,  and  here  the  additional  risk  of  w^oimd  by  a  fragment 
of  a  fractured  femur  also  exists.  The  short  trunk  of  the  deep  femoral 
artery  is  also  held  very  firmly  in  position  by  the  circumflex  branches. 

Signs  of  Wounds  of  the  Femoral  Artery  and  its  Branches. — 
Hsematomata  in  connection  with  wounds  of  these  ^'cssels  reach  the 
largest  size  of  any  met  with  in  the  body,  those  forming  in  connection 
with  the  axillary  artery  being  the  only  ones  which  approximate 
in  size  and  holding  capacity. 

From  the  regional  point  of  view,  wounds  of  the  main  triuiks  may 
be  divided  into  three  classes  : — 

1.  Those  in  which  the  common,  the  superficial,  or  the  deep 
femoral  may  happen  to  be  wounded  while  enclosed  within  the  confines 
of  the  triangle  of  Scarpa.  It  is  not  infrequent^  impossible  to 
determine  which  of  the  three  vessels  is  implicated,  as  the  extravasated 
blood  in  either  case  may  fill  the  triangle,  obliterating  the  normal 
concavity  or  replacing  it  by  a  broadly  convex  sw^elling.  When  the 
"svoimd  of  the  common  femoral  is  near  its  commencement,  the  blood 
may  find  its  way  up  beneath  Poupart's  ligament  and  suggest  that 
the  external  iliac  artery  is  the  vessel  implicated.  Subcutaneous 
ecchymosis  is  often  widespread  in  woxmds  in  this  situation. 

2.  When  the  superficial  femoral  is  woimded  within  the  confines 
of  Hunter's  canal,  a  sw^elling  of  elongated  outline  forms  along  the 
antero-internal  aspect  of  the  thigh  ;  it  is  firm  and  tense,  rarely  extends 
into  Scar^^a's  triangle,  and  subcutaneous  ecchymosis  is  rare.  A 
s])ecial  feature  of  this  hcxmatoma  is  the  part  taken  b}^  the  sartorius 
muscle  in  contributing  to  its  boundaries.  The  muscle,  beyond 
stretching  longitudinally,  widens  out  laterally,  so  that  it  may  often 
be  preferable,  when  trying  to  expose  the  artery,  to  cut  through  the 
fibres  of  the  muscle  rather  than  to  displace  it. 

3.  When  the  Avound  is  a  track  passing  through  the  adductor 
muscles  from  the  front  of  the  thigh,  blood  traA-els  into  the  adductor 


VESSELS    OF    THE    LOWER    EXTREMITY  213 


• 


::.4<-  '^~ 


A'f^-'^A.VE., 


Fig.  55. — Orifice  of  entry  of  a  bullet  which  caused  a  common  femoral  arterio- 
venous aneurysm.  The  minimal  size  of  the  aneurysm  can  be  appreciated  by  regarduig 
the  outline  of  the  groin.  The  cutaneoiis  ecchymosis  over  the  adductor  region  still 
persists,  while  the  papular  form  of  the  orifice  of  entry,  with  its  central  depression,  so 
characteristic  of  such  wounds  during  the  process  of  absorption  and  contraction  of  the 
underlying  blood-clot,  is  well  shown.      Under  the  care  of  Captain  Martin. 


214      GUNSHOT    INJiHIES    TO    THE    BLOOD-VESSELS 

coni])artmcnt,  forming  a  second  large  sac  connected  to  the  anterior 
one  by  a  \ery  narrow  neck  or  channel.  The  blood  in  the  posterior 
segment  of  this  bi-sac  nsiially  coagnlates  early,  and  rarely  forms  a 
])art  of  a  traumatic  aneurysm,  should  this  form. 

Haematomata  in  connection  with  Wounds  of  the  Branches  of 
the  Femoral  Trunlts. — Profunda  Femoris. — Wounds  of  the  profunda 
are  jirobably  far  more  common  than  the  mmibers  furnished  by  lists 
of  injuries  to  the  femoral  arteries  Avould  suggest,  for  there  is  no 
doubt  that  in  many  instances  a  clinical  diagnosis  of  wound  of  the 
common  femoral  artery  is  arrived  at,  when  the  deep  femoral  is  really 
the  vessel  Avhich  has  been  injured. 

This  series  includes  6  cases  in  which  isolated  injuries  to  the 
profunda  were  disclosed  by  operation.  Of  these  patients  3  died, 
and  of  the  3  who  recovered,  2  were  eventually  discharged  from  the 
service  as  permanently  unfit,  and  in  the  third  the  limb  was  in  far 
from  good  condition.  A  brief  abstract  of  the  histories  will  perhaps 
best  serve  to  explain  this  very  unsatisfactory  experience,  since 
isolated  occlusion  of  the  profunda  involves  the  least  serious  inter- 
ference with  the  circulation  of  the  limb  of  any  of  the  three  trunks. 

Case  47. — Pte.  F.  was  admitted  with  a  shell  wound  of  the  thigh,  one 
and  a  quarter  by  one  inch  in  size,  three  inches  below  tlie  mid-point  of 
Poupart's  ligament,  and  apparently  superficial  in  nature.  The  wound  was 
fairly  clean  on  admission,  there  was  some  swelling  of  the  thigh,  no  pulsation, 
and  the  tibial  pulses  were  normal. 

Two  days  afterwards  there  was  a  marked  increase  in  anaemia,  associated 
with  great  increase  in  the  size  of  the  thigh,  and  the  development  of  pulsa- 
tion and  a  systolic  bruit.  The  swelling  extended  from  the  level  of  the 
anterior  superior  spine  to  the  middle  of  the  thigh.  A  temporary  elastic 
ligature  was  applied  to  the  cominon  femoral  artery,  the  swelling  was  incised, 
and  two  pints  of  clot  were  evacuated.  A  lateral  wound  was  discovered  on 
the  outer  side  of  the  origin  of  the  deep  femoral  artery  ;  a  ligature  was  applied 
below  this,  and  the  common  femoral  artery  definitely  closed  also.  After 
four  days'  satisfactory  progress,  gangrene  of  the  toes  set  in,  and  a  few  days 
later  the  man  suecunabed  to  a  general  toxaemia. 

Case  48. — Pte.  G.  was  admitted  with  two  wounds,  one  penetrating  the 
right  chest,  the  second  traversing  the  buttocks  and  wounding  the  rectum. 
A  large  hajmatoma  was  present  in  Scarpa's  triangle.  During  the  following 
week  the  temperature  rose  (reaching  103°),  with  occasional  rigors,  and  the 
haematoma  showed  signs  of  breaking  down. 

Under  spinal  anaesthesia  the  suppurating  haematoma  was  incised  ;  it 
extended  deeply  through  the  obturator  foramen,  and  the  common  femoral 
vessels  were  felt  pulsating  in  its  anterior  wall.  On  the  same  night  a  severe 
secondary  haemorrhage  took  place  ;  this  was  controlled  by  placing  a  ligature 
on  the  common  femoral  artery,  but  the  patient  died  a  few  hours  later.  A 
subsequent  examination  of  the  limb  showed  the  deep  femoral  artery  to  have 
been  completely  severed  at  its  origin  from  the  common  femoral.  It  had 
no  doubt  been  thrombosed,  but  the  clot  had  given  way  as  a  result  of  secondary 
hifeetion. 


VESSELS    OF    THE    LOWER    EXTREMITY  215 

Case  49. — Pte.  G.  A  slit  shell  wound  was  present  above  the  hiner 
third  of  Poupart's  ligament.  There  was  no  history  of  jirimary  ha;rnorrnagc, 
but  Scarpa's  triangle  was  now  filled  by  a  large  clot  which  pulsated  en  masse. 
There  was  no  bruit  audible  on  auscultation.  The  tibial  pulses  were  absent, 
the  foot  was  red,  and  there  were  some  patches  of  ecchymosis  upon  it.  Pulse 
108,  temperature  102-5°. 

A  provisional  diagnosis  of  wound  of  either  the  common  femoral  or 
external  iliac  artery  was  made.  During  the  next  four  days  the  clot  showed 
signs  of  commencing  disintegration,  and  the  mass  decreased  in  size,  the 
foot  meanwhile  commencing  to  mummify. 

On  the  seventh  4ay  a  secondary  haemorrhage  occurred,  and  the  external 
iliac  was  ligatured  in  continuity.  Haemorrhage  recurred  two  days  later, 
and  was  arrested  by  placing  a  second  ligature  on  the  common  femoral 
artery.  The  patient  died  shortly  afterwards  from  the  combined  effects  of 
haemorrhage  and  septic  absorption.  The  profunda  was  found  to  be  com- 
pletely cut  off  from  its  origin. 

Of  the  remaining  three  cases,  which  recovered,  in  one  secondary 
haemorrhage,  and  in  two  extension  of  the  ha^matoma,  formed  the 
indications  for  the  operative  intervention  which  was  a  means  of 
chnching  the  diagnosis.  In  one  case  the  wound  was  actually  a 
lesion  of  the  back  of  the  common  feinoral  at  the  point  of  origin  of 
the  profunda,  and  all  three  trunks  were  tied.  In  the  second  the 
profunda  was  tied  locally,  and  later  the  common  femoral  for  the 
arrest  of  secondary  haemorrhage  on  the  tenth  day.  In  the  third,  a 
case  of  compound  fracture  of  the  femin-,  the  profunda  was  tied 
locally  for  secondary  haemorrhage  occurring  on  the  sixth  day.  The 
ultimate  result  in  these  cases  is  given   above. 

Consideration  of  these  histories  illustrates  the  inicertainty  in 
diagnosis  which  attends  injiiries  to  the  profunda  artery,  and  what  is 
more  important,  the  influence  exerted  by  an  incorrect  diagnosis  on 
the  treatment  and  subsequent  course  of  the  cases.  A  few  points 
help  in  arriving  at  a  correct  opinion,  but  they  can  only  be  regarded 
as  affording  circumstantial  evidence,  thus  :  (1)  The  direction  of  the 
wound  track,  as  indicated  by  the  situation  of  the  apertures  of  entry 
and  exit,  taken  into  consideration  with  the  attitude  of  the  body  and 
limb  when  the  wound  was  received,  or  the  position  of  a  retained 
missile  ;  (2)  Determination  of  the  point  at  which  the  arterial  bruit 
is  loudest ;  (3)  The  retention  of  practically  normal  tibial  pulses. 
The  result  of  my  own  experience  is  to  lead  me  to  approach  any 
hsematoma  in  Scarpa's  triangle  with  an  open  mind,  and  in  no  case 
of  urgency  to  apply  more  than  a  provisional  control  to  the  common 
femoral  artery  until  ocular  demonstration  has  shown  that  vessel  to 
be  the  one  wounded. 

Circumflex  Branches. — ^What  has  been  said  regarding  the  trunk 
of  the  profunda  femoris  applies  equalh^  to  the  cases  of  injury  to  the 
circumflex  branches,  and  here  again  7  cases  were  accompanied  by 
a  mortality  of  3. 


21G      GUNSHOT    I XJ I  NIKS    TO    THE    BLOOD-VESSELS 

In  these  instances,  however,  tlie  mortality  was  not  so  directly 
influenced  by  the  preliminary  diagnosis.  In  all  three  fatal  cases 
direct  local  ligature  of  the  wounded  branch  Avas  effected  ;  one  patient, 
suffering  from  a  serious  fractiu-e  of  the  femur,  died  from  the  combined 
effects  of  hfcmorrhage  and  shock  ;  a  second  as  the  result  of  repeated 
secondary  ha-morrhages  from  an  infected  wound  ;  and  the  third  from 
causes  of  which  I  am  ignorant. 

Certain  small  points  may  aid  in  locating  a  wound  to  one  of  the 
circumflex  branches.  The  size  of  the  hfcmatoma  is  absolutely  no 
guide,  for  quite  as  much  blood  may  be  extravasated  as  if  one  of  the 
larger  tnuiks  had  been  wounded.  The  same  points  already  enumerated 
imder  the  heading  of  the  profunda  should  be  taken  into  consideration  ; 
and  beyond  these  it  should  be  borne  in  mind  that  the  extravasation 
tends  to  follow  the  course  of,  and  correspond  with  that  of,  the  vessels 


Pig_  56.— Wound  of  internal  circumflex  artery,  with  secondary  extension  along  the 
line  of  the  external  circumflex. 

themselves.  Thus,  a  wound  of  the  internal  circumflex  may  lead  to 
the  development  of  a  hcxmatoma  in  the  adductor  region,  although 
the  compartment  has  not  been  traversed  by  the  missile ;  and,  generally 
speaking,  the  swelling  indicative  of  the  hfcmatoma  tends  to  spread 
widely  in  a  transverse  direction  to  the  long  axis  of  the  thigh  {Fig.  56). 
These  special  points  may  be  illustrated  by  the  following  case  :— 

Case  50.— Pte.  A.  Type  bullet  wound,  the  aperture  of  entry  being- 
situated  one  inch  below  Poupart's  ligament,  and  over  the  line  of  the  right 
femoral  vessels  ;    that  of  exit  was  in  the  right  buttock. 

On  admission,  a  diffuse  swelling  occupied  Scarpa's  triangle,  pulsation 
was  strongest  just  below  the  aperture  of  entry,  a  localized  thrill  was  palpable 
in  this  position,  and  a  machinerv  murmur,  not  very  widely  distributed,  was 


VESSELS    OF    THE    LOWER    EXTREMITY  217 

audible.  The  apex  of  the  heart  was  in  the  left  nipple  line,  and  a  systolic 
murmur  was  audible  here. 

The  patient  was  kept  at  complete  rest,  and  the  dilTiise  swellin<>-  ^rufhi- 
aily  localized  itself  to  the  inner  side  of  the  femoral  vessels.  The  walls  of 
the  sac  increased  in  firmness,  and  the  tibial  pulses  were  maintained  through- 
out. The  comparative  distal  blood-pressure  in  the  two  limbs,  taken  a  month 
after  reception  of  the  injury,  was — right  120  mm.  of  mercury,  left  1.50  mm. 
Meanwhile  the  physical  signs  remained  vmaltered,  and  the  strength  of  the 
purring  thrill  in  the  femoral  vein  appeared  to  point  to  a  direct  communi- 
cation between  the  main  artery  and  vein. 

At  the  end  of  two  months  a  sudden  increase  in  the  size  of  the  ha;matoma 
took  place,  and  this  now  extended  outwards  to  the  right  margin  of  the  thigh 
{Fig.  56),  and  the  femoral  vessels  could  be  felt  to  be  beating  independently 
along  the  inner  aspect  of  the  blood  sac.  The  murmur  audible  over  this  new 
extension  was  almost  purely  systolic  in  character. 

An  incision  was  made  extending  from  just  below  Poupart's  ligament 
for  six  inches  downwards,  so  as  to  allow  a  provisional  controlling  ligature 
to  be  placed  on  the  common  femoral  artery.  When  the  ligature  had  been 
placed  upon  the  vessel,  a  second  trunk  was  felt  pulsating  beneath,  so  that 
it  was  clear  that  a  high  division  was  present,  and  a  ligature  was  passed 
around  the  second  trunk. 

The  sac  was  now  cleared  and  opened,  and  the  two  trunks  were  found 
to  be  both  located  upon  its  anterior  wall.  From  the  outer  side  of  the  deep 
trunk  two  branches  of  about  equal  size  originated,  and  the  wound  was  found 
to  be  in  the  upper  of  these.  A  ligature  including  the  satellite  vein  was 
applied  on  either  side  of  the  wound,  and  when  the  provisional  control  on 
the  main  trunks  was  released,  no  bleeding  or  recurrence  of  the  thrill  and 
murmur  followed.     (G.  H.  M.) 

The  sac  proved  to  consist  of  two  segments,  the  primary  one  following 
the  course  of  the  internal  circumflex  artery  into  the  adductor  compartment, 
the  later  one  tracking  outwards  in  the  line  of  the  external  circumflex  branches. 

After  an  uneventful  course  the  patient  was  evacuated  to  England. 
The  ultimate  result  was  not  considered  sufficiently  satisfactory  for  the  man 
to  be  returned  to  active  service,  but  he  resumed  his  occupation  as  a  miner, 
and  has  had  no  further  trouble  with  the  limb. 

Prognosis  and  Treatment. — The  total  mortality  amongst  170 
cases  of  injury  to  the  femoral  vessels  amomited  to  23  (13-5  per  cent). 
In  several  of  the  patients  associated  injuries  were  concerned  in  the 
ultimate  issue.  Deaths  followed  injuries  to  the  common  femoral  in  5 
instances,  to  the  superficial  femoral  in  10,  to  the  profunda  in  3,  and  to 
the  circumflex  branches  in  3.  In  14  of  the  23  fatal  cases  an  opera- 
tion was  performed  for  direct  treatment  of  the  wound  of  the  artery. 
In  the  remaining  9  cases,  1  died  from  exhaustion  consequent  on  the 
primary  haemorrhage  accompanying  the  injurj^  3  after  exploratory 
operations,  2  after  amputation  of  the  limb,  1  from  haemorrhage 
resulting  from  incautiously  opening  a  large  ha^matoma  without 
having  previously  established  provisional  control  of  the  main  trunk, 
and  1  from  causes  of  which  no  details  are  available. 

In  the  case  of  93  of  the  170  patients,  operations  were  performed 


218      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

for  the  lioaturc  oi'  one  or  other  of  the  femoral  arteries.  The  operations 
were  distriljuted  as  follows : — 

Common  Femoral — Cases,  14;  cures,  2  ;  recoveries,  5  ;  deaths,  7. 
In  9  cases  the  artery  alone  was  tied  ;  amongst  these,  gangrene  of 
varying  extent  followed  in  4,  and  6  of  the  patients  died.  In  5  cases 
the  artery  and  vein  were  occluded  simultaneously  ;  amongst  these 
patients,  gangrene  of  varying  extent  occurred  in  3,   and  1  died. 

Superficial  Femoral. — Cases,  79  ;  cures,  52  ;  recoveries,  20 ; 
deaths,  7.  In  25  cases  the  artery  alone  was  tied  ;  amongst  these 
patients,  gangrene  of  varying  extent  developed  in  4  (16  per  cent), 
and  4  deaths  (16  per  cent)  occurred.  In  54  cases  the  artery  and 
vein  were  tied  simultaneously  ;  amongst  these  patients,  gangrene  of 
varying  extent  developed  in  7  (12-9  per  cent),  and  3  deaths  (5-5 
per  cent)  occurred. 

If  the  two  series  be  combined,  we  have  a  total  of  93  operations, 
with  19  cases  of  gangrene  (20-4  per  cent),  and  14  deaths  (15  per  cent). 
Amongst  those  cases  in  which  the  artery  alone  was  tied,  the 
incidence  of  both  local  gangrene  and  of  death  was  considerably  the 
greater.  Thus  :  Artery  alone,  34 ;  gangrene,  8  (24-5  per  cent)  ; 
deaths,  7  (20-5  per  cent).  Artery  and  vein,  59  ;  gangrene,  10  (16-9 
per  cent)  ;    deaths,  7  (11-7  per  cent). 

The  causes  of  death  in  the  14  cases  following  operation  were  as 
follows  :  Septic  infection,  1  ;  gas  gangrene,  3  ;  primary  haemorrhage, 
1  ;  operative  haemorrhage,  1  ;  secondary  haemorrhage,  septic  infection, 
and  exhaustion,  8. 

If  the  cases  in  which  ligature  was  imdertaken  as  a  primary 
measure  or  during  the  first  two  daj-s  be  taken  separately,  the  results 
attained  are  as  follows.  For  the  purjDose  of  this  computation ,  two 
small  series  of  cases  are  available,  one  of  25  selected  from  the  170 
cases  already  considered,  and  one  of  18  obtained  from  reports  fur- 
nished by  surgeons  working  at  casualty  clearing  stations.  These  are 
set  out  separately  in  the  subjoined  table,  because  they  offer  definite 
evidence  as  to  the  better  results  attained  by  primary  oj^eration  when 
it  is  practicable. 

Primary  Ligature  of  Superficial  Femoral  Artery. 


Gangrene 
Gas  gangrene 
Amputation 

Deaths    . . 


Hospitals  on  lines 

of  communication, 

25  cases 


10 


Casualty  clearing; 
stations, 
18  cases* 


1 


1  (not  fatal)     !     1  (fatal) 
5  (1  death)  4  (1  death) 

1  \     1 


*  Also  two  cases  of  ligature  of  common  femoral  ;    no  complications 


VESSELS    OF    THE    LOWER    EXTREMITY  219 

If  both  sets  of  cases  be  taken  together,  with  a  view  to  obtaining 
an  average  result  of  the  work  extending  over  the  whc^Je  line,  we  have 
45  cases  of  early  ligature  of  the  artery,  amongst  which  gangrene 
occurred  11  times  (24-4  per  cent),  9  amputations  had  to  be  performed 
(20  per  cent),  and  2  deaths  occurred  (4-4  per  cent). 

In  15  of  the  45  cases  the  artery  alone  was  tied  ;  amongst  these 
gangrene  occurred  5  times  (33-3  per  cent),  and  there  was  no  death. 
The  remaining  30  were  treated  by  simultaneous  ligature  of  the  artery 
and  vein  ;  amongst  these  gangrene  occurred  in  6  (20  per  cent),  and 
death  in  2  (6-6  per  cent). 

The  Occurrence  of  Gangrene  following  Injuries  to  the 
Femoral  Arteries. — Amongst  the  170  cases,  gangrene  of  a  varying 
extent  followed  injuries  to   the  femoral  vessels  in  36  (21-1  per  cent). 

Pre-operative  Gangrene. — In  11  instances  gangrene  was  a  direct 
result  of  the  injury  alone.  In  2  the  injuries  involved  the  common 
femoral  trunk,  and  in  both  the  foot  and  leg  were  involved.  In  7 
instances  the  wound  was  of  the  superficial  femoral ;  in  2  the 
toes  only  were  involved,  in  1  the  whole  foot,  in  8  the  foot  and  leg, 
and  in  1  isolated  patches  of  skin  alone  were  implicated.  Thrombosis 
was  followed  by  gangrene  twice  ;  in  one  case  this  was  limited  to  the 
foot,  in  the  second  both  foot  and  leg  were  involved. 

Post-operative  Gangrene. — Gangrene  followed  the  application  of 
a  ligature  in  25  cases  ;  but  in  4  of  these  the  gangrene  was  due  to 
anaerobic  infection.  In  the  remaining  21  cases  the  gangrene  was  of 
the  anemic  type  ;  but  it  must  be  added  that  at  least  half  the  number 
of  patients  were  suffering  from  the  effects  of  septic  absorption  from 
their  wounds,  and  in  8  of  them  attacks  of  secondary  hfcmorrhage 
formed  the  indication  for  occlusion  of  the  artery.  The  common 
femoral  was  the  seat  of  ligature  in  6  of  the  patients  ;  in  1  the 
gangrene  did  not  extend  beyond  the  toes,  in  2  the  whole  foot  was 
involved,  and  in  3  both  foot  and  leg.  The  superficial  femoral  was 
the  seat  of  ligature  in  15  cases  ;  in  6  the  gangrene  did  not  extend 
beyond  the  toes,  in  1  half  the  foot  was  involved,  in  1  a  limited 
slough  formed  in  the  sole,  and  in  6  the  foot  and  leg  were  imj^licated. 

It  will  be  observed  at  once  that  the  extent  of  the  gangrene  was 
not  a  wide  one  on  the  whole;  in  less  than  half  (9  out  of  21)  did 
the  process  involve  the  leg.  It  should  also  be  noted  that  involvement 
of  the  leg  seldom  depassed  the  dangerous  area — i.e.,  the  junction  of 
the  middle  and  lower  thirds,  the  point  where  the  arterial  supph^  is 
normally  least  abundant.  In  fact,  the  gangrene  of  the  leg  was  often 
patchy,  involving  the  leg  in  this  area  and  often  the  heel,  with  patches 
of  skin  still  retaining  vitality  intervening.  Two  further  influencing 
factors  also  need  to  be  taken  into  consideration  :  (1)  The  patients 
had  often  lain  out  on  the  groiuid  for  hours  or  even  days,  sometimes 


220     GUNSHOT    IXJIHIES    TO    THE    BLOOD-VESSELS 

with  a  self-applied  tourniquet  on  the  linil)  ;  and  (2)  A  large  jn-opor- 
tion  Averc  suffering  from  septic  infeetion  of  Aarying  degree,  or  were 
the  subjects  of  multiple  wounds.  AVhen  all  these  luifavonrable 
conditions  are  considered,  I  do  not  think  the  incidence  of  20-5  per 
cent  can  be  regarded  as  a  surprising  one.  In  this  particular  series, 
moreover,  a  decided  fall  in  the  incidence  of  gangrene  corresponded 
with  a  generally  improved  method  of  primary  wound  treatment, 
showing  the  influence  likely  to  be  exerted  by  septic  absorption. 

The  presence  of  the  tibial  pulses  at  the  ankle,  regarded  as  an 
indication  of  the  persistence  of  a  column  of  blood  circulating  in  the 
main  trunk,  must  always  be  of  importance  ;  but  in  the  early  stages 
of  injuries  to  the  femoral  artery  it  is  no  proof  of  an  enlarged  collateral 
circulation.  When  existent,  it  is  promptly  extinguished  by  ligature 
of  the  main  vessel,  and  no  evidence  has  been  obtained  from  the  cases 
under  consideration  that  the  previous  existence  of  a  pulse  guarantees 
an  earlier  return  after  the  operation.  On  the  other  hand,  the  dis- 
apjDcarance  of  the  tibial  pulses  while  a  case  is  under  observation  is 
a  serious  sign  of  increasing  pressure  and  obstruction,  especially  if  at 
the  same  time  an  arterial  murmur  which  has  been  present  disappears. 
Under  these  circumstances  surgical  operation  is  imjDcratively 
demanded,  and  may  stave  off  impending  gangrene  and  save  the 
vitality  of  the  limb. 

Resort  to  ligature  has  not,  however,  proved  of  great  serA'ice  in 
the  complete  preservation  of  the  limb  when  signs  of  impending 
gangrene  have  reached  a  serious  degree.  The  operation  has  ^^I'oved 
most  satisfactory  in  those  instances  in  which  pressure  by  large 
collections  of  extravasated  blood,  especially  when  coagulation  has 
taken  place,  are  exerting  pressure  both  on  the  main  trunk  and  the 
collateral  branches.  In  one  or  two  instances  the  line  of  threatening- 
gangrene  has  been  seen  to  recede  somewhat,  and  thus  the  eventual 
amputation  has  been  able  to  be  carried  through  a  lower  point.  Some 
further  remarks  upon  this  subject  will  be  foTuid  in  the  section  devoted 
to  the  popliteal  arterj^. 

Arterial  Haematomata  and  False  Aneurysms. — Arterial  hixmato- 
mata  developed  in  36  instances,  and  in  27  of  these  it  was  necessary 
to  operate  in  the  early  stages. 

Six  of  the  patients  (16-6  per  cent)  died,  1  from  secondary  hcTmor- 
rhage,  gangrene,  and  exhaustion,  2  as  the  result  of  septic  absorption 
and  secondary  hcTmorrhage,  1  from  haemorrhage  occurring  diu'ing 
the  operation,  1  from  gas  gangrene,  and  1  from  septic  infection  of 
the  peritoneal  cavity.  Nine  of  the  patients  were  able  to  be  transferred 
to  England  without  operation.  It  will  be  noted  that  in  this  particular 
the  arterial  injiu'ies  compare  imfavoiu-ably  with  the  arterio-venous, 
as,  in  the  latter,  25  out  of  51  patients  Avere  able  to  be  transferred  to 


VESSELS    OF    THE    LOWER    EXTREMITY  221 

England  without  operation.  The  scries  thus  supports  the  statement 
made  in  the  general  section  of  this  essay ;  for  analysis  shows  that 
extension  of  the  hscmatoma,  secondary  h;emorrhage,  and  secondary 
inflammation — all  conditions  associated  with  the  degree  of  tension 
existent  in  the  hscmatoma — are  far  more  common  in  pure  arterial 
haematomata.  Again,  routine  examination  of  the  distal  pulse  shows 
this  generally  to  be  more  diminished  in  volume,  or  more  frequently 
abolished  when  the  lesion  is  purely  arterial  in  character. 

The  indications  for  operation  were  :  pre-operative  gangrene  in 
3  of  the  patients,  secondary  haemorrhage  in  2,  extension  of  the 
hasmatoma  in  5,  and  local  inflammatory  changes  in  2.  Primary  or 
secondary  amputation  was  performed  in  3  cases  (8*3  ]3er  cent)  ; 
in  one  of  the  patients  the  vascular  lesion  accompanied  a  severe 
compound  fracture  of  the  femur.  The  artery  alone  was  tied  18 
times ;  post-operative  gangrene  followed  the  operation  twice,  and 
all  the  fatalities  occurred  in  this  series.  The  artery  and  vein  were 
tied  simultaneously  in  6  cases,  and  in  one  instance  the  artery  alone 
was  tied  because  the  vein  was  already  thrombosed. 

Arterio-venous  Aneurysms  and  Aneurysmal  Varices.  —  Arterio- 
venous communications  were  permanently  established  in  51  instances. 

Of  these  patients  7  died  (13-7  per  cent),  4  without  operation,  and 
3  after  ligature  of  the  vessels.  The  4  non-operative  deaths  resulted, 
in  1  as  a  result  of  general  septic  infection  dependent  upon  a  suppurating 
amputation  stiuiip  of  the  opposite  thigh  {Fig.  57),  in  1  from  septic 
absorption  in  combination  with  severe  primary  haemorrhage,  and  in 
2  from  complications  which  were  not  recorded. 

In  15  cases  treated  in  the- early  stage,  the  operation  consisted  in 
quadruple  ligature  and  removal  of  the  sac.  The  indications  for  inter- 
vention were  in  2  instances  secondary  haemorrhage,  in  6  extension, 
in  4  the  large  size  of  the  hacmatoma,  and  in  only  1  was  the  operation 
done  in  the  settled  false  aneurysm  stage. 

Aneurysmal  varices  were  treated  by  quadru2:>le  ligatiu'c  and 
excision  in  7  instances,  with  invariable  success  ;  3  of  the  patients 
rejoined  their  regiments  within  a  few  months.  The  operations  for 
arterio-venous  haematoma  wTre  followed  in  2  instances  by  anaomic 
gangrene  necessitating  amputation  of  the  leg.  Three  of  the  patients 
died,  2  from  anaerobic  gangrene,  and  1  without  any  obvious  cause 
beyond  shock  being  discovered  at  the  autopsy. 

Of  the  remaining  11  men  who  were  operated  upon,  I  have  been 
unable  to  obtain  any  subsequent  particulars,  except  in  the  case  of 
one  who  was  discharged  from  the  service  as  permanentlj'  unfit  for 
military  duty.  Neither  have  I  been  able  to  obtain  any  further  details 
of  the  25  men  who  were  transferred  to  England  prior  to  operation. 

Of   the    whole    79    patients    in    whom    the    femoral    artery    was 


222      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

ligatured,  I  have  been  able  to  trace  only  15  to  their  ultimate  issue. 
Of  these,  7,  were  returned  to  duty  (three  of  them  subsequently  being 
killed  on  the  field  of  battle  within  a  few  months),  and  8  were 
diseharged  from  the  service  as  permanentlv  luifit  for  military  duty. 


Fig.  57. — Femoral  arterio-venous  aneurysm.  The  dilated  vein  is  laid  open,  and 
within  are  seen  the  termination  of  the  profunda  vein  and  the  arterio-venous  channel. 
The  aneurysmal  sac  is  of  the  small  typical  form  wedged  into  the  angle  between  the 
two  trunks. 


Some  of  the  latter  arc,  however,  earning  their  li\ing  in  civil  occupa- 
tion, even  in  such  work  as  a  miner's.  I  feel  no  doubt,  moreo^'er,  that 
a  large  proportion  amongst  those  on  Avhom  primary  operations  have 
been  performed  will  eventually  suffer  little  inconvenience.  None  the 
less  it  is  obviously  a  rare  event  for  the  limb  actually  to  regain  its  full 
normal  volume  and  strenoth. 


VESSELS    OF    THE    LOWER    EXTREMITY  223 

After-results. — Circumstances  have  not  allowed  a  full  investigation 
of  the  after-results  which  have  come  imder  vay  notice  ;  but  a  short 
resume  of  the  conditions  which  have  been  observed  may  be  usefid.  I 
have  had  the  opportvniity  of  examining  a  number  of  men  in  England 
in  whom  either  the  artery  or  the  artery  and  vein  have  been  ligatured 
abroad.  An  inspection  of  the  limb  in  such  cases,  at  a  period  of  from 
two  to  three  weeks  after  occlusion  of  the  artery,  fully  warrants  a  report 
as  to  their  good  condition.  As  the  patient  lies  in  bed,  the  injured 
limb,  in  fact,  often  appears  the  better  of  the  two.  It  is  as  large  as 
or  larger  than  the  uninjured  limb,  and  also  retains  the  normal  outline 
of  a  well-developed  member.  This  appearance  does  not  depend  on 
subcutaneous  oedema,  at  any  rate  not  sufliciently  to  be  demonstrable 
b}^  making  pressure  pits  with  the  tip  of  the  finger.  On  palpation, 
the  explanation  is  foimd  in  the  condition  of  the  muscles.  The 
muscles  of  the  calf  of  the  uninjured  limb  will  have  acquired  the  loss 
of  tone  which  inevitably  follows  disuse;  while  those  of  the  limb  in 
which  the  artery  has  been  tied  are  abnormally  firm  and  retain  their 
outline  fully.  The  muscles  exhibit,  in  fact,  the  condition  characteristic 
of  the  early  stages  of  muscular  ischscmia,  the  degree  varying  in  indi- 
vidual cases.  In  some  instances  this  is  almost  the  onl}^  phenomenon 
which  attracts  notice  ;  in  others  a  varying  degree  of  stiffness  of  the 
ankle-joint  and  the  articulations  of  the  toes  is  superadded. 

Examination  of  the  tibial  pulses  rarely  reveals  a  volume  in  any 
degree  reaching  the  normal.  There  is  great  difficulty  in  determining 
what  should  be  considered  a  normal  date  for  the  re-a^jpearanee  of 
a  palpable  pulse  in  the  posterior  tibial  artery  at  the  ankle,  or  in  the 
dorsalis  pedis  artery.  There  is.  also  a  great  variation  in  the  capacity 
of  the  individual  surgeon  to  determine  the  presence  or  absence  of 
slight  pulsation.  The  surgeons  at  some  of  the  casualty  clearing 
stations  have  made  a  small  number  of  observations  on  this  point. 
A  palpable  pulse  was  reported  to  have  reappeared  in  7  cases  out  of 
25 — at  the  end  of  twenty-four  hours  in  1,  at  the  end  of  four  days  in  2, 
at  the  end  of  eight  days  in  1,  and  at  the  end  of  nine  days  in  3. 

For  purposes  of  comparison,  20  cases  observed  in  London  may 
be  taken.  In  7  of  these  the  pulse  was  palpable  at  the  end  of  three, 
seven,  fourteen,  sixteen,  twentj^-six,  fifty-two,  and  ninety  days 
respectively  ;  but  these  dates  may  not  really  correspond  with  the 
actual  day  on  which  the  pulse  returned  ;  moreover,  a  recently-returned 
pulse  is  often  very  variable  in  strength,  and  not  constantly  present. 
The  negative  results  are  therefore  of  more  real  value.  Of  these  there 
were  13.  Amongst  these  no  palpable  pulse  Avas  present  at  the  end 
of  three  days  in  2,  or  in  the  others  after  ten,  fourteen,  tAventy, 
twenty-six,  thirty-one,  thirty-two,  forty-one,  fifty-eight,  eight^^-two, 
one    hundred    and    sixteen,    and    one    hundred    and    sixtv-tAvo    davs 


224      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

rcspccti\-e]y.  Of  the  1.3  cases  in  Avliieh  the  pulse  remained  absent. 
in  2  instances  limited  gangrene  had  occurred,  but  in  the  remaining 
11  the  foot  was  apparently  in  good  condition. 

^Vith  resumption  of  the  upright  position  on  the  part  of  the  patient, 
a  certain  amount  of  oedema  always  develops  ;  this  is  rarely  persistent. 
but  it  may  last  for  Avceks  or  months.  The  severit}'  of  the  primary 
injury  and  the  amount  of  cicatricial  tissue  in  the  limb  are  potent 
factors  in  the  amount  of  trouble  caused  by  oedema,  and  cases  in  which 
a  fracture  of  the  femur  has  accompanied  the  arterial  lesion  are  the 
most  unfavourable. 

The  peri]:)heral  blood-pressure  rarely  if  ever  equals  that  of  the 
uninJTu-ed  limb  ;    in  all  the  cases  I  have  examined  it  has  been  from 


Fig.  58. — Skiagram  showing  a  refined  shrapnel  ball  in  the  adductor  region  of  the 
left  thigh  which  had  wounded  the  vessels  and  given  rise  to  a  common-femoral  arterio- 
venous aneurysm.     Captain  Oreaves. 


20  to  60  mm.  of  mercury  lower  than  that  of  the  sound  side.  The 
diminution  after  ligatiu-e  of  the  artery,  moreo^'er,  is  considerably 
greater  than  that  caused  by  the  presence  of  an  aneurysm.  Although 
the  blood-pressure  tends  to  rise  with  the  lapse  of  time,  I  have  seen 
no  case  in  which  it  reached  the  normal.  The  temperature  of  the  foot 
remains  lowered,  and  it  is  doubtful  whether  the  foot  ever  becomes  as 
resistant  to  external  changes  of  temperature  as  is  normal. 

The  degree  to  which  loss  of  vohmie  of  the  limb  may  attain  is 
variable.  In  my  exjjerience,  rapid  severe  wasting  has  onlj^  been 
seen  in  early  operations,  or  in  patients  the  subjects  of  infection.  It 
is  rare,  and  practically  never  occiu'S  after  remote  operations.  A 
permanent  loss  of  volume  of  the  limb  of  a  slighter  nature,  however, 


VESSELS    OF    THE    LOWER    EXTREMITY  225 

follows  occlusion  of  the  main  artery  even  in  the  most  satisfactory 
cases.  In  such,  a  loss  of  circumference  of  the  calf  of  from  half  an 
inch  to  one  inch  will  be  found  on  measurement. 

Grave  trophic  changes  in  the  foot,  of  the  degree  not  uncommon 
in  the  hand,  are  distinctly  rare  in  my  experience,  a  fact  which  supports 
the  theory  of  the  almost  invariable  dependence  of  such  changes  on 
associated  nerve  injury. 

Suture  of  the  Femoral  Vessels. — This  series  contains  only  9 
operations,  1  of  the  common  femoral,  and  8  of  the  superficial  femoral 
arter)?^ ;  3  of  the  operations  were  undertaken  in  the  primary  stage^ 
3  were  intermediate,  and  3  were  remote. 

The  three  primary  operations  afford  little  information,  for  two 
of  them  were  of  a  complicated  nature.  In  one  the  suture  was  of  an 
arteriotomy  wound  which  had  been  made  for  the  evacuation  of  a 
thrombus  following  a  contusion  ;  recurrence  of  the  thrombus  ensued. 
The  second  (Captain  Gabe)  illustrates  the  dangers  to  which  a 
promising  primary  operation  may  be  exposed  ;  the  patient  arrived 
at  a  hospital  on  the  lines  of  communication  on  the  fifth  day, 
after  suture  of  a  lateral  wound  of  the  femoral  artery,  with  an 
excellent  posterior  tibial  pulse ;  besides  the  wound  of  the  thigh, 
multiple  woinids  of  other  parts  of  the  body  were  present,  and  the 
patient  succumbed  after  a  few  days  to  an  acute  general  infection. 
The  third  case  (Captain  Cowxll)  was  a  success  ;  a  lateral  wound  of 
the  artery  as  it  lies  in  Plunter's  canal  was  closed  by  stitches,  and  the 
line  of  union  strengthened  by  a  flap  of  tissue  obtained  from  the 
aponeurotic  roof  of  the  canal  ;    viability  of  the  artery  was  retained. 

The  three  secondarj^  or  intermediate  operations  afforded  successful, 
if  not  perfect,  results. 

Case  51. — Arterial  haematoma  of  seven  days'  standing.  A  definite, 
stiff  sac  had  formed  around  a  lateral  rent  in  the  artery  almost  amounting  to 
a  complete  division.  A  double  row  of  sutures,  the  second  implicating  the 
adventitia  alone,  was  inserted,  somewhat  restricting  the  lumen  of  the  vessel. 
The  tibial  pulse  was  diminished  in  volume,  but  was  persistent.  On  the 
fourteenth  day  the  peripheral  blood-pressure  was  determined  as  90  mm. 
of  mercury  in  the  injured  to  140  mm.  in  the  sound  limb.  An  uneventful 
recovery  took  place,  but  it  has  not  been  possible  to  trace  the  patient  since 
he  left  France.     (G.  H.  M.) 

Case  52.  (Colonel  Gunn). — Arterial  haematoma,  developing  secondarily 
on  the  twelfth  day,  in  a  patient  with  a  fractured  femur.  Exploration  revealed 
a  through-and-through  perforation  of  the  artery.  The  two  apertures  were 
closed  by  suture  and  an  uneventful  recovery  took  place.  No  observation  of 
the  peripheral  blood-pressure  was  made. 

Case  53.  (Major  Hope). — Secondarj^  haemorrhage  occurring  on  the 
third  day  from  a  small  shell-wound.  A  rent  a  quarter  of  an  inch  long  was 
sewn  up,  and  the  fragment  of  shell  removed  from  Hunter's  canal.  The 
posterior  tibial  pulse  persisted,  but  in  reduced  volume. 

15 


220      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

Of  the   three   remote   operations,   one   died. 

Case  54. — Aneurysmal  varix  of  six  months'  standing.  This  man  had 
been  returned  to  duty  after  beino-  wounded  six  months  jjreviouslj^  ;  the 
arterio-venous  commiuiication  had  not  been  diseovered.  The  man  was 
sent  down  the  hne  because  he  complained  of  jmin  when  marching.  A 
vertical  slit  in  the  side  of  the  superficial  femoral  artery  was  closed  by  suture, 
and  the  femoral  vein  was  tied  {see  Fig.  6,  p.  14).  Prior  to  the  operation 
the  peripheral  blood-pressure  in  the  two  limbs  was  equal  at  140  mm.  of 
mercui'v.  After  the  operation  it  fell  to  125  in  the  sound  limb,  and  110  in 
the  afl'ected  one.  The  tibial  pulse  was  retained,  but  was  smaller  in  volume 
than  that  of  the  sound  limb.     (G.  H.  M.) 

Case  55. — Arterial  aneurysm  of  the  common  femoral  artery  of  six 
weeks'  standing.  The  bullet,  which  had  entered  above  Poupart's  liga- 
ment, passed  downwards,  and  wounded  the  common  femoral  artery  on  its 
posterior  aspect.  The  sac  dipped  into  the  iliopsoas  muscle.  The  sac  was 
separated  from  the  artery,  and  the  opening  in  the  vessel  closed.  Early 
thrombosis  took  place  at  the  site  of  suture,  and  the  posterior  tibial  pulse 
was  obliterated  ;    but  the  patient  made  a  good  recovery.     (G.  H.  M.) 

Case  56. — Arterio-venous  aneurysm  of  superficial  femoral  artery  at  the 
apex  of  Scarpa's  triangle.  Vertical  lateral  slits  in  the  artery  and  vein  were 
closed  by  stitches.  The  wound,  which  communicated  with  an  unhealed 
sinus  in  the  buttock,  was  acutely  reinfected  by  streptococcus,  and  the 
patient  succumbed  to  toxaemia  on  the  ninth  day,  after  an  attack  of 
secondary  haemorrhage. 

The  series  is  small  for  drawing  any  wide  conclusions,  but  it  shows 
that  in  four  of  the  023erations  the  viability  of  the  vessel  was  main- 
tained, while  in  three  it  was  certainly  not.  In  no  case  was  an  ideal 
result  attained,  as  estimated  by  the  volume  of  the  posterior  tibial 
pulse  and  the  peripheral  blood-pressure  in  the  limb.  The  tAvo 
fatalities  were  in  no  way  dependent  upon  the  nature  of  the  operation 
performed,  and  the  second  could  certainly  have  been  avoided  had 
not  the  presence  of  a  deep  sinus  in  the  buttock  been  overlooked. 

The  Use  of  Tuffier's  Tubes. — In  5  cases  an  attempt  at  temporary 
maintenance  of  the  circulation  was  made.  In  two  instances  success 
was  attained.  In  one  of  these  the  tube  was  left  in  position  twenty-one 
days  (Colonel  Kidd)  ;  the  pulse  i:)ersisted  continuously,  and  on  the 
sixtieth  day  the  peripheral  blood-pressure  in  the  affected  limb  stood 
at  120  mm.  of  mercury  as  against  135  mm.  in  the  sound  one.  In 
the  second  case  (Captain  J.  Fraser)  the  tube  Avas  retained  for  seventy- 
tAVO  hours,  and  the  patient  was  cA'acuated  later  with  a  persisting  pulse. 
In  two  unsuccessful  cases,  the  limb  in  one  became  gangrenous  and 
had  to  be  amputated  after  tAventy  hours  :  in  the  second  the  tube 
Avas  retained  six  days,  Avhen  gas  gangrene  superA'ened,  and  the 
patient  succumbed  after  an  amputation.  The  fifth  case  AA^as  one  in 
Avhich  traimiatic  thrombosis  haAnng  occurred,  the  artery  Avas  incised, 
the  clot  cAacuated,  and  a  tube  introduced.  A  fresh  thrombus  formed 
in  three  hours,  and  the  artery  Avas  tied. 


VESSELS    OF    THE    LOWER    EXTREMITY  227 

The  Lines  of  Treatment  to  be  followed  in  dealing  with  Cases 
of  Injury  to  the  Femoral  Vessels. — TJic  tlirco  mctliods  lor  (lcaliii<>' 
with  these  injuries  have  been  practically  illustrated  in  the  preceding 
paragraphs.  It  remains  to  consider  shortly  what  may  he  the  indi- 
cations for  the  choice  of  cither. 

When  the  conditions  as  to  wounds  of  the  soft  parts,  operative 
facilities,  and  the  general  state  of  the  patient  are  good,  lateral  wounds 
and  traversing  perforations,  if  the  character  of  the  defect  in  the  wall 
of  the  vessel  is  suitable,  may  be  sutured. 

When  the  lesion  is  of  a  more  extensive  character,  the  question 
of  resection  and  end-to-end  union  may  be  considered.  The  choice 
of  this  method  will  probably  depend  on  the  individual  proclivities 
of  the  surgeon.  In  certain  positions — for  example,  the  immediate 
neighbourhood  of  Poupart's  ligament,  close  to  the  origin  of  the  pro- 
funda, or  at  the  extreme  lower  end  of  Hiuiter's  canal — it  is  difficult 
to  mobilize  the  vessel  sufficiently  to  allow  of  its  being  luiited  with 
technical  ease,  and  I  do  not  think  the  method  should  be  chosen.  In 
other  parts  of  the  course  of  the  vessels  the  technique  is  comparatively 
simple  ;  but  further  experience  is  needed  as  to  the  ultimate  results  of 
end-to-end  union  before  it  can  be  confidently  recommended.  It 
should  not  be  adopted  in  any  case  where  the  patient  is  liable  to  early 
transport. 

When  the  character  of  the  lesion  of  the  arterial  wall  precludes 
any  idea  of  essaying  repair,  the  introduction  of  a  Tuffier's  tube  may 
be  considered.  Major-General  W^allace  has  suggested  this  as  advisable 
as  a  means  of  lessening  the  risk  of  the  supervention  of  gas  gangrene, 
the  occurrence  of  which  is  so  highly  favoured  by  limitation  of  the 
blood-supply  to  the  periphery  of  the  limb. 

The  operation  of  ligature  is  applicable  in  any  case  ;  it  requires 
less  perfect  surroundings  and  equipment  than  either  of  the  other 
methods  ;  it  takes  less  time  to  perform  on  a  patient  suffering  from 
shock  or  the  effects  of  loss  of  blood  ;  and  it  is  likely  to  hold  the  field 
as  a  routine  procedure.  The  results  given  above  indicate  that 
simultaneous  ligature  of  the  artery  and  accompanying  vein  should 
be  the  rule ;  also,  that  when  only  a  strand  of  the  arterial  wall 
remains,  this  should  always  be  divided,  to  allow  of  retraction  of 
the  ligatured  ends  of  the  vessel. 

In  the  intermediate  stage,  the  majority  of  the  injuries  are  best 
treated  either  by  ligature  or  by  the  introduction  of  a  Tuffier's  tube. 

In  the  remote  or  late  stage,  suture  should  be  the  invariable  aim 
of  the  surgeon.  The  junction  tube  is  unnecessary,  as  the  collateral 
circulation  may  be  relied  upon  ;  while  ligature  can  always  be  resorted 
tf>  if  suture  is  found  to  be  impracticable  after  the  lesion  has  been 
exposed. 


228     GUNSII07'    IXJUIUES    TO    THE    BLOOD-VESSELS 

Remarks  on  the  Operative  Procedures  for  Dealing  with  Injuries 
to  the  Femoral,  Vessels. — Operations  I'or  injuries  to  these  vessels 
are  required  more  frequently  than  for  those  for  any  others  in 
the  body  ;  and  it  may  be  laid  down  as  a  general  statement  that  with 
the  exception  of  operations  upon  the  arteries  at  the  root  of  the  neck, 
which  possess  special  dangers  of  their  own,  no  operations  call  for 
more  capacity  and  resource  on  the  part  of  the  surgeon  than  those  in 
the  thigh.  It  is  true  that  the  mere  placing  of  a  ligature  upon  the 
femoral  arter}^  is  one  of  the  simplest  and  most  straightforward  proce- 
dures in  surgery  ;  but  gimshot  injuries  to  the  vessels  of  the  thigh, 
especially  in  the  region  included  between  the  origin  of  the  profunda 
artery  and  the  mid-point  in  Hunter's  canal,  may  demand  all  the  skill 
and  resource  of  the  experienced  surgeon,  to  secure  the  main  trunks 
or  wounded  branches  of  the  intricate  network  fomid  in  this  situation. 
Provisional  ligatures  placed  upon  the  common  and  superficial  femoral 
arteries  may  often  exert  but  little  influence  in  restraining  haemorrhage 
when  the  collateral  supply  derived  from  the  branches  of  the  internal  iliac 
passing  to  the  buttock  is  freely  developed  ;  and  it  behoves  the  operator 
to  be  careful  how  he  occludes  any  factors  in  this  supply  except  when 
absolutely  necessary,  as  far  as  the  eventual  nutrition  of  the  limb  is 
concerned  if  the  main  trunk  needs  to  be  ligatured.  I  have  seen  the 
resources  of  a  good  operator  taxed  to  the  uttermost  on  several 
occasions  in  dealing  with  haemorrhage  from  a  second  wound  of  the 
profunda  or  one  or  more  of  its  branches,  and  even  then  eventually 
he  has  been  comjoelled  to  be  satisfied  with  forcipressiu'e  and  perhaps 
a  plug,  to  restrain  severe  and  persisting  haemorrhage. 

The  first  point  which  arises  in  any  procedure  is  as  to  the  best 
method  of  maintaining  provisional  control  of  the  main  trunks.  In 
the  case  of  the  common  femoral  artery,  a  })rovisional  loop  applied 
to  the  external  iliac  artery  is  the  method  of  choice.  The  artery  may 
be  approached  across  the  peritoneal  ca^'ity,  or  an  extraperitoneal 
operation  may  be  performed.  The  former  is  the  simpler  and  more 
rapid  method,  the  latter  avoids  obvious  risks,  and  is  generalh^  to  be 
preferred.  I  ha^'e  employed  the  rectus  sheath  incision,  and  displaced 
the  peritoneum,  as  in  the  search  for  the  lu-eter.  If  time  or  the 
surrounding  conditions  render  provisional  ligature  of  the  external 
iliac  inadvisable,  recourse  can  be  had  to  an  indiarubber  tourniquet 
of  tubing  the  size  of  the  finger  applied  around  the  waist.  I  have  twice 
used  this  method  with  success,  and  have  seen  no  ill  result  follow. 

When  the  position  of  the  field  of  operation  allows,  an  Esmarch's 
tourniquet  may  be  applied  to  the  thigh.  This  method  is  generally 
preferable,  as  it  permits  the  woiuided  A'cssel  to  be  aj^proached  safely  : 
the  provisional  ligature,  if  necessary,  can  be  placed  nearer  to  tliQ 
wounded    spot,  less  trouble  results   from  blood  brought  to   the  trunk 


VESSELS    OF    THE    LOWER    EXTREMITY  220 

by  collateral  branches  ;  and,  shonld  the  lesion  prove  to  be  one  only 
suitable  for  treatment  by  ligatnre,  muicccssary  interference  with  the 
artery  is  avoided. 

The  incision  made  in  the  line  of  the  artery  needs  to  be  free — 
six,  eight,  or  more  inches  in  length.  The  long  saphenons  vein  should 
be  carefully  preserved,  in  view  of  the  fact  that  the  deep  vein  may 
probably  require  to  be  occluded.  The  sartorius  muscle  may  be  dis- 
placed in  the  usual  manner ;  but  in  recent  cases  where  a  large 
ha:^matoma  is  present  in  Hunter's  canal,  it  is  often  better  to  go  through 
the  muscle.  If  the  collection  of  extravasated  blood  be  large,  the 
vessel  is  liable  to  be  displaced  in  the  direction  of  least  resistance,  and 
will  therefore  most  likely  be  found  in  either  the  inner  or  the  anterior 
wall  of  the  cavity. 

Certain  anatomical  variations  should  be  kept  in  mind  ;  thus,  a 
high  division  of  the  common  femoral  is  not  unusual.  I  have  twice 
come  across  it  in  these  operations.  Unless  recognized,  one  may  unwit- 
tingly leave  the  profunda  uncontrolled.  A  second  not  infrequent 
source  of  confusion  lies  in  the  origin  of  the  external  circumflex  branch 
from  the  femoral  trunk  ;  if  this  arrangement  be  present,  the  profunda 
lies  more  internally  than  usual,  and  cannot  be  got  at  from  the  outer 
side  of  the  superficial  femoral  as  is  usually  the  case.  Great  care  should 
be  taken  to  spare  this  branch  from  injury  ;  and  the  same  caution  is 
needed  with  regard  to  the  anastomotica  magna  when  the  lower  part 
of  Hunter's  canal  is  being  laid  open.  The  latter  point  is  especially 
important  when  it  becomes  necessary  to  divide  the  tendon  of  the 
adductor  magnus,  as  it  may  be,  when  the  artery  is  wounded  in  the 
lower  part  of  the  adductor  canal. 

The  most  trying  cases  to  deal  with  are  those  in  which  the  wound 
is  of  either  the  common  or  superficial  femoral  trunks  in  immediate 
proximity  to  the  origin  of  the  profunda  ;  in  these  instances  the  passage 
of  a  ligature  around  the  profimda  is  often  a  matter  of  great  difficidty. 
The  amount  of  blood  which  may  escape  from  the  distal  end  of  a 
divided  profunda  artery,  brought  from  the  anastomoses  with  the 
branches  of  the  internal  iliac,  is  surprising. 

When  the  vessels  have  been  wounded  in  the  course  of  a  track 
passing  antero-posteriorly  in  the  thigh,  an  hour-glass  sac  is  common. 
The  connecting  opening  in  the  insertion  of  the  adductors  is  often 
small,  but  the  cavity  in  the  adductor  compartment  may  extend  widely 
to  the  back  of  the  thigh.  The  blood  and  clot  should  be  carefully 
removed,  but,  as  a  rule,  no  further  measure  is  needed  ;  and  it  is  not 
advisable  to  drain  such  a  cavity  to  the  back  of  the  thigh  excej^t  in 
exceptional  cases.  The  conditions  may  be  different  when  the  wound 
is  one  of  the  profunda  at  a  small  distance  from  its  origin  ;  imder 
these  circumstances  the  sac  may  be  wholly  accommodated  in  the 
adductor  compartment. 


230      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

The  bifurcation  of  the  conunoii  femoral  provides  an  angle  which 
favours  concomitant  woinid  of  both  vessels  should  the  missile  pass 
between  them  ;  this  fact  must  always  be  borne  in  mind  in  ex]iloring 
an  injury  in  this  position.  Fig.  54  illustrates  an  injuiy  of  this  class. 
Should  the  wound  be  situated  in  the  angle  itself,  it  may  sometimes 
be  easier  to  anastomose  the  two  vessels  than  to  close  the  two  oj^enings 
separately  by  suture. 

In  all  early  cases,  the  rule  that  no  ligature  should  be  i^laced 
definitely  xipon  the  main  trunk  until  the  surgeon  is  sure  that  the 
bleeding  does  not  come  from  one  of  the  branches,  must  never  be 
departed  from.  In  dealing  with  arterial  ha:'matomata  or  aneurysms 
in  which  the  vessel  commimicates  with  the  sac  by  two  separate 
openings,  closure  of  the  artery  by  terminal  suture  is  preferable  to 
ligatiu'e,  as  by  this  means  interference  with  the  vascular  cleft  is 
avoided. 

The  above  observations  refer  almost  purely  to  operations  imder- 
taken  in  the  early  stages  ;  operations  for  the  treatment  of  definite 
false  aneurysms  or  arterio-venous  lesions  are  easier,  and  require  no 
further  description  than  that  afforded  by  the  remarks  in  the  general 
section. 

Lastlv,  a  word  may  be  said  regarding  isolated  injuries  to  the 
femoral  vein.  Hfemorrhage  from  these  wounds  is  as  a  rule  arrested 
spontaneously ;  but  in  some  instances  this  is  not  the  case,  and  a  ve'ry 
extensive  hsematoma,  and  great  swelling  of  the  thigh,  may  develop. 
The  possibility  of  this  lesion  being  the  only  one  must  always  be  borne 
in  mind,  especially,  in  my  experience,  when  the  swelling  of  the  thigh 
is  great  and  diffuse.  The  cases  often  present  great  operative  difliculty  : 
first,  in  localizing  the  wound  ;  and  secondly,  in  applying  the  ligature, 
since  a  wounded  vein  is  much  more  diflicult  to  clear  than  the  stronger- 
walled  artery. 

POPLITEAL     ARTERY. 

Injuries  to  the  popliteal  vessels  enjoy  a  more  evil  rei^utation  in 
regard  to  their  primary  consequences  than  those  affecting  any  other 
artery  of  the  limbs  ;  and  in  their  ultimate  results  they  hold  a 
position  comparable  to  that  of  the  axillary. 

The  series  under  consideration  consists  of  85  cases.  The  incidence 
in  the  two  limbs  was  equal :  thus,  of  50  injuries,  the  vessels  of  the 
right  side  were  involved  24  times,  those  of  the  left  26  times.  In  the 
early  stages  of  the  war  a  considerable  number  of  injiu-ies  by  bullets 
were  met  with,  but  during  the  latter  three  years  the  proportion  of 
shell  injuries  was  overwhelming.  Among  the  cases  reaching  the  lines 
of  communication,  associated  extensive  wounds  of  the  soft  parts  were 
rare  ;   thus,  amongst  50  cases,  in  22  the  wounds  were  limited  through- 


VESSELS    OF    THE    LOWER    EXTREMITY  231 

and-through  tracks,  in  4  the  wounds  were  large,  and  in  "li  tlic  missile 
was  retained. 

Primary  ha?morrhage  is  noted  to  have  been  severe  in  14  cases 
(16-4  per  cent),  and  secondary  haemorrhage  necessitated  operative 
intervention  in  12  (14-1  per  cent). 

The  local  injury  to  the  vessels  tends  to  be  severe  in  type.  The 
liability  to  severe  injury  to  the  artery,  and  to  associated  lesions  ol" 
the  artery  and  vein,  as  also  the  serious  consequences  which  result, 
depend  in  great  measure  on  the  local  anatomical  arrangement.  The 
walls  of  the  popliteal  space  are  particularly  firm  and  resistant  in 
every  direction.  The  nature  of  the  floor — formed  by  the  bones — exposes 
the  vessels  not  only  to  risk  of  contusion,  but  also  to  penetration  by 
fragments  of  bone  ;  the  lateral  boundaries,  held  together  by  the  stout 
popliteal  fascia,  and  in  great  part  tendinous  in  nature,  are  very 
tense  when  the  knee-joint  is  fully  extended;  and  the  fascial  roof  is 
imusually  strong  and  inelastic.  Hence,  when  effusion  of  blood  takes 
place  into  the  space,  the  pressure  exerted  upon  both  the  main 
trunks  and  their  branches  is  very  considerable. 

The  vessels,  both  on  their  entry  and  on  their  exit  from  the  space, 
are  very  firmly  fixed  in  position  by  the  fibrous  arches  formed  by  the 
insertion  of  the  adductor  magnus,  and  the  origin  of  the  soleus,  respec- 
tively. Further,  the  artery  is  immobilized  by  the  articular  branches, 
both  laterall}^,  and  anteriorly  by  the  azygos  branch.  Lastly,  the 
relation  of  the  artery  and  the  vein  is  a  particularly  intimate  one. 
The  state  of  tension  induced  by  full  extension  of  the  knee-joint 
accounts  for  the  wide  gaping  which  accompanies  extensive  lateral 
w^ounds  ;  this  causes  these  injuries  to  simulate  complete  severance 
closely,  and  no  doubt  favours  the  occurrence  of  primary  haemorrhage. 

Contusion  of  the  Popliteal  Vessels.  —  This  form  of  injury 
accompanies  a  large  proportion  of  all  wounds  ;  and,  while  tending 
to  prevent  or  oppose  the  occurrence  of  primary  haemorrhage,  yet,  by 
occasioning  thrombosis,  it  takes  a  prominent  place  in  giving  rise  to 
an  unfortunate  issue  in  many  cases.  Thrombosis  of  the  artery  was 
the  prominent  featiu'e  of  7  of  the  cases  in  this  series,  and  in  all  of 
these  except  one,  gangrene  of  the  limb  necessitating  amputation 
was  a  direct  consequence.  In  two  instances  the  popliteal  vein  had 
suffered  a  penetrating  injury,  and  in  one  of  these  it  was  ligatiu'ed 
primarily  ;  in  each  case  the  tibial  pulses  Avere  extinguished  at  an  early 
moment,  and  in  both  gangrene  of  the  leg  was  established  on  the 
sixth  day  ;  the  artery  in  one  of  the  cases  is  depicted  in  Fig.  12. 
In  two  cases  secondary  ha?niatomata  developed,  on  the  thirteenth 
and  eighteenth  day  respectively ;  in  both  the  tibial  pulses  were 
impalpable,  and  amputation  became  necessary,  in  one  instance  for 
the  removal  of  the  gangrenous  limb,  and  in  the  other  on  account  of 


232      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

toxjrmia  secondary  to  the  large  infeeted  wound  of  the  pophteal  space. 
In  the  fifth  case,  in  Avhich  a  fracture  of  the  femur  was  present, 
gangrene  commenced  to  develop  on  tlie  fifth  day,  the  obvious  signs 
corresponding  in  their  appearance  with  the  transference  of  the  limb 
from  a  Wallacc-Maybiuy  to  a  Mclntyre  splint  ;  in  this  instance 
the  vessels  had  suffered  complete  division,  and  up  to  the  occurrence 
of  the  gangrene  the  blood-supply  had  been  maintained  bj'^  a  greatly 
enlarged  Aertical  collateral  chain,  which  in  turn  had  undergone 
thrombosis  ;  this  chain  had  formed  a  superficial  trimk  Avhich  the 
surgeon  likened  to  the  popliteal  artery  itself  in  size.  The  sixth 
case  Avas  one  of  thrombosis  secondary  to  contusion  by  a  shrajjuel 
ball ;  the  tibial  pulses  were  absent,  and  gangrene  began  to  develop 
on  the  second  day  ;  on  the  fourth  day  the  limb  was  ampiitatcd, 
but  the  patient  died  six  days  later  from  toxaemia.  In  the  seventh 
case  secondar}^  ha;morrhage  occurred  on  the  third  day,  and  the 
artery  and  vein  were  ligatured  ;  on  the  tenth  day  the  leg  and  foot 
became  gangrenous,  and  amputation  was  performed  ;  the  posterior 
tibial  artery  and  vein  were  found  to  be  occluded  throughout  their 
coiu'se  by  a  recent  thrombus  ;    the  anterior  tibial  vessels  were  patent. 

Wounds    of    the    Popliteal    Vessels. — A  note   of  the   form  of  the 
vascular  wound    is  recorded  in    49    cases.     In  32   (65-3   per  cent)   it 


Figs.  59,  60. — Skiagrams  showing  the  position,  shape,  and  size  of  a  fragment  of 
shell  which  had  wounded  the  popliteal  artery  and  gi\-en  rise  to  the  formation  of  an 
arterial  aneurysm.      Captain   Greaves. 


was  lateral  in  type;    in   19  of  these  an  associated  injur}'-  to  the  vein 
was  present,  in  two  instances  a  through-and-through  perforation,  and 


VESSELS    OF    THE    LOWER    EXTREMITY  233 

ill  one  traumatic  thrombosis  due  to  contusion.  In  15  instances  (30'0 
per  cent)  complete  severance  of  continuity  was  noted  ;  in  8  of  these 
the  vein  was  wounded,  and  in  1  thrombosed. 

It  may  be  remarked  here  that  some  observers  rej)ort  cases 
as  complete  division  of  the  artery  where  a  narrow  strand  of  the  wall 
really  persists  ;  and  in  this  relation  it  may  be  noted  that  amongst  the 
32  cases  of  lateral  wound  just  quoted,  at  least  10  are  included  that 
might  have  been  regarded  as  complete  divisions  by  some  operators. 

Only  two  through-and-through  perforations  are  recorded  (4  per 
cent),  and  experience  would  lead  one  to  expect  this  to  be  the  case  in 
the  presence  of  such  a  large  proportion  of  injuries  caused  by  fragments 
of  shells.  In  two  instances  the  missile  remained  lodged  within  the 
artery,  and  controlled  haemorrhage  until  it  was  removed  ;  the  missile 
was  in  one  instance  a  fragment  of  shrapnel  case,  in  the  other  a  German 
bullet  ;    the  latter  is  depicted  in  position  in  Fig.  16,  p.  28. 

Complications  of  Injuries  to  the  Popliteal  Vessels.  —  The  com- 
plications most  often  met  with  are  :  ha?marthrosis  or  synovial 
effusion  into  the  knee-joint  ;  small  localized  fractures  of  the  femur 
or  tibia ;  and  lesions  of  the  popliteal  nerves.  This  series  affords 
rather  meagre  information  on  these  points,  a  circumstance  which 
depends  on  the  fact  that,  in  the  early  history  of  these  cases,  in  the 
majority  the  vitality  of  the  limb  is  the  all-absorbing  moment.  In 
only  two  cases  was  a  major  fracture  of  the  femur  present  ;  this  was 
complicated  in  one  instance  by  gangrene  necessitating  amputation, 
and  in  the  other  by  an  infected  haemarthrosis  which  ceded  to  a 
single  aspiration.  None  of  the  minor  fractures  took  any  serious 
part  in  the  clinical  course  of  the  cases.  The  knee-joint  is  noted  to 
have  suppurated  and  led  to  amputation  twice  in  the  early  and 
twice  in  remote  stages.  In  10  cases  synovial  effusion  was  a  promi- 
nent feature,  but  led  to  no  ill  result.  It  is  somewhat  remarkable 
that  injuries  to  the  popliteal  nerves  are  mentioned  in  only  5 
instances,  4  of  the  more  fixed  external,  and  1  of  the  internal.  Some 
lesions  were  undoubtedly  overlooked  ;  but,  on  the  other  hand,  the 
wounds  in  the  majority  of  instances  were  narrow  through-and-through 
tracks,  taking  a  more  or  less  transverse  or  oblique  course  ;  hence 
they  were  unlikely  to  involve  the  internal  popliteal  nerve,  which 
runs  a  superficial  course  in  the  centre  of  the  space  ;  in  large  open 
wounds  of  the  popliteal  space  this  nerve  is   often  involved. 

Clinical  Characteristics  of  Injuries  to  the  Popliteal  Vessels. — 
In  no  other  position  in  the  body  are  the  signs  of  an  arterial  lesion  so 
prompt  and  obvious.  In  at  least  two-thirds  of  the  cases  the  tibial 
pulses  are  extinguished  at  an  early  date  ;  coolness  of  the  limb,  and 
pallor  or  cyanosis  and  swelling  of  the  calf,  are  commonly  early  and 
well-marked  signs.     When  the  pulses  are  present  at  the  ankle,  they 


234      aUXSIIOT    L\J['h'Ii:s    TO    THE    BLOOD-l'ESSELS 

arc  diniinislu'd  in  volume  ;  in  my  cx]K'ricncc  a  good  tibial  pulse 
is  rare,  except  in  cases  of  immediate  I'ormation  of  an  aneinysmal 
varix  or  a  small  arterio-^■ell()Us  liamatoma. 

The  situation  is  one  in  which  the  application  and  prolonged 
retention  of  a  tourniquet  is  likely  to  be  particularly  harmful,  not 
only  as  causing  dcpri\-ation  of  the  arterial  su])ply,  but  also  in  causing 
adema.  Unfortunately,  the  application  of  a  tourniquet  to  the  lower 
third  of  the  thigh  is  not  onl}^  an  easy  procedure,  even  to  the  patient 
himself,  but  it  is  also  particularly  effective,  and  hence  the  more  to 
be  dreaded.  It  is  not  at  all  uncommon  in  these  cases  to  meet  with 
the  persisting  line  of  constriction  due  to  the  use  of  a  toiu-niquet  put 
on  by  the  patient  or  one  of  his  mates. 

The  swelling  consequent  on  extravasation  of  blood  in\olves 
chiefly  the  calf ;  it  is  rare  for  the  blood  to  travel  along  the  course 
of  the  anterior  tibial  vessels  into  the  anterior  compartment.  In  some 
cases  the  oedema  is  very  abundant,  and  may  simulate  blood  extra\asa- 
tion  ;  it  does  this  the  more  easily,  since  extravasation  into  the  calf 
lies  in  a  space  which  allows  extension  to  its  extreme  limits,  and  any- 
thing like  a  marginal  boundary  of  clot,  such  as  develops  in  the  thigh, 
is  usually  absent.  A  marked  degree  of  cj^anosis  suggests  associated 
injury  to  the  vein  ;  but  it  may  be  said  that  clinically  it  is  generally 
impossible  to  be  certain  that  an  isolated  lesion  of  the  vein  is  present, 
since  the  signs  may  be  identical  wdth  those  of  a  wounded  artery. 
There  is  little  doubt  that  isolated  injuries  to  the  vein  are  more  common 
than  the  number  included  in  this  series  would  suggest,  and  imless 
accompanied  by  thrombosis  of  the  artery,  the  injin-y  may  not  cause 
any  serious  consequences. 

The  lesions  most  liable  to  be  overlooked  are  direct  anemysmal 
varices.  I  have  twice  seen  this  happen  where  one  small  wound, 
amongst  several  distributed  over  the  lower  extremity,  happened  to 
have  implicated  the  vessels.  In  other  instances  a  perforating  wound 
of  the  knee-joint  may  attract  the  main  attention  of  the  surgeon  and 
the  associated  vascular  lesion  escape  detection.  Such  varices  are 
often  attended  by  no  signs  except  the  local  miu'mur  and  thrill.  The 
importance  of  auscultation  in  such  injm-ies  is  evident,  as  it  certainly 
prevents  any  chance  of  the  lesion  being  missed.  Transmission  of 
the  local  systolic  murmur  to  the  cardiac  apex  was  noted  in  more 
than  one-third  of  the  cases  of  arterial  or  arterio-venous  haematomata, 
and  may  sometimes  lead  to  the  discovery  of  an  unsuspected  arterial 
injury. 

Arterial  and  arterio-venous  ha^matomata  of  the  popliteal  vessels 
offer  some  special  characters.  The  first  of  these  is  the  diffuse  nature 
of  the  primary  SAvelling,  Avhich  tends  to  invade  the  whole  space  and 
give  rise   to   a  general  heaving  type  of  pulsation  like  that  observed 


VESSELS    OF    THE    LOWER    EXTREMITY  2ti5 

when  a  spontaneous  aneurysm  has  eommeneed  to  diffuse.  A  seeond 
peeuharity  hes  in  the  diffieulty  whieh  attends  any  attenii)t  to 
detei'mine  with  certainty  by  chnical  examination  whether  the  primary 
injmy  has  involved  the  artery  alone,  or  both  artery  and  vein.  Thus, 
in  four  of  the  cases  under  consideration,  the  presence  of  a  purely  systolic 
bruit  caused  the  ha?matoma  to  be  diagnosed  as  arterial  ;  yet  at  the 
operation  the  vein  was  found  to  be  either  extensively  lacerated  or 
completely  severed.  This  diflficulty  is  by  no  means  confined  to  the 
popliteal  vessels,  especially  if  the  vein  be  severed,  but  it  is  certainly 
more  commonly  encountered.  Delayed  development  of  the  hacmatoma 
is  also  more  commonly  met  with  in  this  situation,  pulsation  and  bruit 
appearing  at  the  eighth,  tenth,  or  a  later  day — in  fact  at  much  the 
same  period  that  the  wall  of  the  artery  might  give  way  and  a  secondary 
haemorrhage  occur.  This  is  probably  to  be  explained  by  the  facts 
that  primary  thrombosis  of  a  severely-contused  vessel  occurs,  and 
that,  except  in  the  upper  and  the  lower  part  of  its  course,  the 
vessel  receives  little  direct  support  from  muscles,  and  there  is  no 
opportunity  for  adhesion  to  neighbouring  structures.  The  primary 
blood  effusion  spreads  in  one  direction  only,  downward  into  the 
calf,  but  the  blood  effused  between  the  two  layers  of  the  muscles 
of  the  calf  never  takes  any  part  in  the  eventual  false  aneurysm, 
and  seldom  or  never  pulsates  in  the  early  stage,  since  the  dividing 
neck  formed  by  the  arch  of  the  soleus  is  too  narrow  to  allow  the  wave 
to  pass  freely.  The  presence  of  pulsation  in  the  calf  suggests  that 
the  wound  is  of  the  posterior  tibial  artery. 

The  fact  that  such  a  large  proportion  of  injuries  to  the  popliteal 
vessels  require  early  treatment,  much  limits  the  number  of  fully- 
developed  traumatic  aneurysms,  or  even  well-localized  hac^matomata. 
In  this  series  only  28  out  of  85  can  be  said  to  have  passed  beyond 
the  wounded  artery  stage.  Of  these,  11  were  arterial  haematomata  ; 
12  were  arterio- venous  haematomata ;  and  in  5  the  clinical  signs 
suggested  aneurysmal  varix. 

Amongst  the  11  arterial  haematomata,  6  early  operations  were 
called  for,  and  only  5  amongst  the  17  obvious  arterio-venous  lesions, 
evidence  in  favour  of  a  statement  made  in  the  general  section  as  to 
the  more  dangerous  natiu-e  of  the  pure  arterial  lesion.  It  will  be 
convenient  to  detail  shortly  in  this  place  the  nature  of  these  opera- 
tions and  their  results. 

Six  operations   on   arterial  hcematomata  : — 

Case  57. — Wound  of  artery,  ligature  on  the  tenth  day,  eighteen  days 
later  the  patient  was  evacuated  to  England  in  good  condition.  There  had 
been  some  effusion  into  the  knee-joint  which  had  given  rise  to  no  anxiety. 
Two  months  later  the  knee-joint  suppurated  and  amputation  became  neces- 
sary. A  year  later  the  man  was  discharged  from  the  service,  permanently 
unfit  for  military  duty. 


230     GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

Case  58. — Ligature  of  artery  on  the  eleventh  day.  Two  months  later 
the  foot  and  leg  were  in  good  eondition,  but  there  was  no  tibial  pulse,  and 
some  ellusion  in  the  knee-joint.  At  the  end  of  four  and  a  half  months  an 
artlireetomy  was  jjerformed,  and  the  man  was  finally  discharged  as  per- 
manently unfit  for  military  duty  eleven  months  froni  the  date  of  the  accident. 

Case  59. — The  aitery  was  ligatured  on  the  fifth  day  for  extension  of  the 
Jia?matoma.  The  immediate  result  was  good,  but  no  further  information 
is  fortlicoming. 

Case  60. — Artery  ligatured  on  the  sixth  day  ;  the  immediate  result  was 
good,  but  no  further  information  is  forthcoming. 

Case  61. — The  artery  and  vein  were  ligatured  on  the  twenty-fifth  day 
for  extension  with  disappearance  of  the  pulse.  The  immediate  result  was 
good,  but  the  man  was  discharged  as  permanently  unfit  for  military  duty 
live  months  later,  as  a  consequence  of  concurrent  injury  to  the  external 
popliteal  nerve. 

Case  62. — Ligature  of  artery  and  vein  on  the  fifth  day  for  threatening 
gangrene.     Immediate  result  good. 

Five  operations  on  arterio-venous  ha^matomata  : — 

Case  63. — Artery  and  vein  ligatured  on  the  ninth  day.  An  amputation 
for  rapid  gangrene  was  performed  forty-eight  hours  later,  and  the  patient 
died. 

Case  64. — Ligature  of  artery  and  vein  on  the  third  day ;  swollen  tender 
limb  and  good  tibial  pulses.     Immediate  result  good. 

Case  65. — Ligature  of  artery  and  vein  on  the  ninth  day.  Immediate 
result  good.  Four  months  later  the  man  went  on  furlough  able  to  walk 
two  miles. 

Case  66. — Ligature  of  artery  and  vein  on  eighth  day  ;  anterior  tibial 
pulse  palpable,  the  posterior  absent.  In  this  case  the  wound  in  the  artery 
was  not  localized,  and  a  month  later  an  aneurysm  developed.  The  femoral 
artery  was  then  ligatured  in  Hunter's  canal,  and  the  man  finally  rejoined, 
sixteen  months  after  the  injury. 

Case  67. — Ligature  of  artery  and  vein  for  an  aneurysm  of  three  months' 
standing  ;  there  were  signs  of  serious  venous  obstruction,  and  feeble  tibial 
pulses.     The  immediate  result  was  excellent. 

Aneurysmal  Varix. — Only  one  case  was  operated  upon.  The 
artery  and  vein  were  tied,  the  varix  excised  on  the  nineteenth  day, 
and  a  fragment  of  shell  removed.     The  immediate  result  was  good. 

These  results  speak  for  themselves  without  further  comment. 
It  will  be  observed  that  only  two  of  the  patients  arc  known  to  have 
rejoined  their  battalions  on  active  service. 

Gangrene. — The  incidence  of  gangrene  is  enormously  high,  and 
this  would  appear  to  be  due  to  two  factors  :  first,  that  injuries  to 
this  artery  tend  to  be  very  severe  ;  secondly,  that  the  collateral 
circulation  is  not  a  ver}^  efficient  one.  This  may  in  part  depend  on 
the  fact  that  the  liability  of  no  tnuik  artery  in  the  body  is  more 
interfered   with   by   postiu'c  than  the   popliteal,    hence   compensation 


VESSELS    OF    THE    LOWER    EXTREMITY  2.*J7 

by  the  collateral  circulation  is  constantly  called  into  action  under 
normal  circumstances.  The  articular  branches  of  the  popliteal  on 
which  it  mainly  depends  arc,  however,  so  fixed  in  the  early  part 
of  their  course  that  dilatation  beyond  that  called  for  imder  normal 
conditions  is  not  easy.  The  great  enlargement  of  the  vertical  chain 
which  follows  occlusion  of  the  trunk,  especially  that  along  the  great 
sciatic  nerve,  seems  to  favour  this  theory.  In  one  of  the  cases  under 
consideration,  at  an  amputation  for  gangrene  following  ligature,  a 
vertical  vessel  approaching  in  size  the  popliteal  itself  was  found,  in 
which  recent  thrombosis  had  taken  place. 

Extinction  of  the  peripheral  pulse  is  notably  frequent  in  these 
injuries  ;  thus,  of  48  cases,  the  posterior  tibial  pulse  was  extinguished 
in  36  (75  per  cent),  and  present,  usually  in  diminished  volume,  in  12 
(25  per  cent). 

It  has  been  suggested  that  pressure  on  the  vessel  by  blood 
extravasated  in  the  popliteal  space  is  responsible  for  the  obstruction  ; 
but  operative  exploration  has  not  substantiated  this  view.  On  the 
other  hand,  when  the  extravasation  reaches  the  calf  in  abundance, 
there  is  no  doubt  that  the  pressure  exerted  on  the  peripheral  circula- 
tion is  a  potent  factor  in  the  causation  of  gangrene.  The  occurrence 
of  thrombosis  is  another  element  to  be  kept  in  mind.  Some  remarks 
are  made  later  as  to  how  far  threatening  gangrene  is  likely  to  be 
modified  by  opening  the  popliteal  space  and  ligaturing  the  injured 
vessel. 

Consideration  of  the  cases  included  in  this  series  indicates  that 
the  occurrence  of  gangrene  is  considerably  influenced  by  the  situation 
of  the  wound  of  the  arter}^  Thus,  of  60  eases,  we  find  :  injuries  to 
the  upper  third  15,  gangrene  3  (20  jDcr  cent)  ;  injuries  to  the  middle 
third  25,  gangrene  10  (40  per  cent)  ;  injuries  to  the  lower  third  20, 
gangrene  7  (35  per  cent). 

The  incidence  of  gangrene  in  the  whole  series  of  85  was  39,  or 
45-8  per  cent.  In  21  eases  (24-7  per  cent)  the  gangrene  commenced 
before  any  operative  interference  ;  in  18  instances  (21-1  per  cent) 
it  followed  an  operation.  In  all  of  the  cases  except  two  the  gangrene 
was  purely  anaemic  in  type  ;  in  one  of  the  two  exceptions  the  an- 
aerobic gangrene  was  certainly  secondary  to  arterial  gangrene,  and  in 
the  other  probably  so. 

The  gangrene  was  usually  of  an  extensive  character,  necessitating 
amputation  of  the  thigh  ;  thus,  in  the  21  eases  in  which  gangrene 
supervened  independently  of  operation,  in  2  only  was  it  limited  to 
the  foot.  Among  the  18  post-operative  cases,  we  find  it  was  limited 
in  2  cases  to  the  toes,  in  3  to  localized  patches  on  the  feet,  in  3  to  the 
whole  foot,  while  in  10  it  extended  to  the  leg. 

My   records   show   25   amputations   to   have   been   performed   in 


23S    crxsHcrr  ixjurtes  to  tiie  bloodvessels 

France,  oi'  wliich  24  were  of  the  thioh  and  1  of  the  leg.  Of  the  25 
patients,  3  died  (or  7"6  jx-r  cent).  These  numbers  are  not,  I  beheve, 
accurate  ;  in  any  case  they  are  luirehable  as  to  the  ultimate  number 
of  either  amputations  or  deaths,  as  I  have  been  unable  to  trace  a 
large  ])ro])ortion  of  the  cases  in  England. 

Prognosis  and  Treatment. — As  has  already  been  set  forth,  the 
frequency  with  which  gangrene  follows  injuries  to  the  popliteal  vessels 
is  the  overwhelming  factor  in  determining  the  fate  of  the  limb.  The 
idtimate  results,  in  cases  of  which  the  period  immediately  following 
operation  is  not  unsatisfactory,  are  far  from  encoiu-aging.  I  have 
only  succeeded  in  following  ujd  15  of  the  cases  included  in  the  series, 
and  I  cannot,  perhaps,  better  illustrate  the  common  coiu'se  of  events 
than  by  shortly  quoting  the  reports  obtained. 

Case  68. — Primary  ligature  of  artery  and  vein.  The  immediate  result 
gave  no  cause  for  dissatisfaction.  At  the  end  of  four  months,  the  man 
was  reported  "  convalescent,  but  still  requiring  a  good  deal  of  massage." 

Case  69. — Primary  ligature  of  artery  and  vein.  Sent  to  England  on  the 
twenty-third  day.  A  week  later  a  residual  abscess  was  opened  in  the  pop- 
liteal space.  Suppuration  progressed,  and  the  vitality  of  the  foot  failed. 
Amputation  of  the  thigh  was  performed,  and  at  the  end  of  seven  months 
the  man  was  discharged  from  the  service  as  permanently  unfit. 

Case  70. — Primary  ligature  of  artery  and  vein.  The  immediate  result 
was  satisfactory,  but  three  months  later  the  report  says,  "  the  knee  is  con- 
tracted, and  the  muscles  of  the  leg  are  weak."  Seven  months  later  the 
man  rejoined  the  Flying  Corps. 

Case  71. — Arterial  hsematoma,  extension  on  the  twenty-first  day,  pop- 
liteal artery  ligatured.  The  immediate  result  was  satisfactory  ;  but  one 
month  later  the  man  is  reported  to  have  an  acutely  fiexed  knee  ;  three 
months  later  the  limb  was  amputated  for  a  suppurating  knee-joint  ;  and  at 
the  end  of  thirteen  months  the  man  was  discharged  from  the  service  as 
permanently  unfit. 

Case  72. — Arterial  hsematoma.  Popliteal  artery  and  vein  ligatured  on 
the  eleventh  day.  The  immediate  result  was  good.  Six  months  later  an 
arthreetomy  of  knee  was  performed,  and  at  the  end  of  four  months  the  man 
was  discharged  from  the  service  as  permanently  unfit. 

Co.se  73. — Arterial  haematoma.  Ligature  of  popliteal  artery  and  vein  on 
the  thirteenth  day.  Immediate  result  good.  Five  months  later  the  move- 
ments of  the  knee-joint  are  reported  to  be  restricted  in  range,  and  the  foot 
to  get  cold  and  numb  at  times.  The  patient  left  on  furlough,  so  he  may 
possibly  have  rejoined. 

Case  74. — Arterial  false  aneurysm.  Extension  took  place  at  the  end  of 
four  weeks.  The  man  was  discharged  as  permanently  inifit  five  months 
later,  the  disability  depending  on  concurrent  injury  to  the  external  popli- 
teal nerve. 

Case  75. — Arterio-venous  hgematoma.  Ligature  of  popliteal  artery  and 
vein  on  the  fifteenth  day.  Five  months  later  the  man  was  discharged  on 
furlough  with  the  report  that  he  could  walk  two  miles. 


VESSELS    OF    THE    LOWER    EXTREMITY  239 

Cose  76. — Artcrio-venous  hfematoma.  IJgature  of  tfie  j)C)pIitc'al  artery 
and  vein  on  the  eighth  day.  Seventeen  days  later  the  feiJKjral  artery  was 
ligatnred  in  Ilnnter's  canal  for  recurrent  pulsation  in  the  popliteal  space. 
Eleven  months  later  he  went  on  furlough,  and  ultimately  rejoined  his 
regiment. 

Case  77. — Arterial  ha-matoma.  Ligature  of  femoral  artery  in  Hunter's 
canal  at  the  end  of  three  weeks.  Tlie  man  is  reported  as  up  on  crutches  at 
the  end  of  six  weeks,  with  the  foot  a  little  blue.  The  foot  improved,  and 
ten  weeks  later  the  patient  was  sent  to  a  convalescent  home. 

Case  78. — Wound  of  popliteal  artery.  Primary  proximal  ligature  of 
femoral  in  Hunter's  canal.  Eight  months  later  the  man  was  still  under 
treatment  for  dropped  foot. 

Case  79. — Wound  of  popliteal  artery  and  vein.  Primary  proximal  liga- 
ture of  femoral  in  Hunter's  canal.  Three  years  later,  ulcer  of  the  leg,  and 
persistent  arterio-venous  aneurysm  in  popliteal  space. 

Case  80. — Primary  ligature  of  artery  and  vein.  Immediate  result  good. 
Two  months  later  no  tibial  pulses  were  present  ;  the  knee  could  not  be 
quite  extended  ;  there  was  some  oedema  ;  and  the  leg  ached.  A  year  later 
the  patient  was  discharged  from  the  service  as  permanently  unfit.  Could 
not  walk  more  than  a  mile. 

Some  further  ultimate  results  will  be  found  under  the  headings 
of  "  Tuffier's  Tube  "  and  "  Suture  "  (pp.  241,  242). 

There  is,  I  think,  no  reason  to  believe  that  the  above  ultimate 
results  are  altogether  untrustworthy,  in  spite  of  their  small  number. 
We  may  infer  that  6  men  rejoined  their  regiments,  and  that  7  were 
rendered  permanently  imfit,  2  chiefly  as  a  result  of  existing  injiuy 
to  the  external  popliteal  nerve.  When  it  is  borne  in  mind  that  45 
per  cent  of  the  men  suffering  from  these  injuries  had  already  been 
eliminated  by  the  occurrence  of  early  gangrene  of  the  limb,  and  that 
at  least  6  (7  per  cent)  of  those  who  survived  to  reach  the  lines  of 
communication  died  there,  the  ultimate  prognosis  may  be  regarded 
as  unhappy  in  the  extreme. 

The  first  point  to  be  taken  into  consideration  in  the  treatment 
of  injuries  to  the  popliteal  vessels  is  the  question  as  to  whether,  in 
view  of  the  unfavourable  prognosis  both  with  regard  to  the  immediate 
vitality  of  the  limb  and  the  ultimate  results,  a  more  active  attitude 
should  be  assumed  in  the  face  of  the  primary  injury.  The  cases  under 
consideration,  although  not  collected  with  the  purpose  of  specially 
elucidating  this  question — since  as  far  as  I  know  no  siu'geon  has  taken 
the  line  of  ligaturing  the  ^^essels  primarily  as  a  routine  method — yet 
shed  some  light  on  the  subject.  In  every  instance  primarj^  ligature 
was  undertaken  for  persisting  haemorrhage,  and  28  cases  are  included. 
Of  these,  16  are  obtained  from  the  series  of  85,  and  12  from  direct 
reports  furnished  by  casualty  clearing  stations.  In  20  cases  both 
artery  and  vein  were  occluded,  with  6  cases  of  gangrene  ;  in  8  the 
artery  alone  was  ligatured,  with  2  cases  of  gangrene.     Consideration 


240     aiXSIIOT    IXJURIES    TO    THE    BLOOD-VESSELS 

ol'  thf  coml)inc(l  series  shows  that,  of  28  cases,  in  8  (28-5  per  cent) 
ganorene  is  known  to  have  oeenrred.  and  7  ]:)atients  (25  per  cent) 
were  subjected  to  amjiutation.  It  must  l)e  added  that,  as  regards 
the  12  eases  in  which  reports  from  casualty  clearing  stations  ha^x• 
been  utilized,  2  patients  Avere  so  ill  as  to  need  blood  transfusion, 
and  in  only  2  does  the  history  after  operation  extend  beyond  a  few 
days  to  a  week ;  hence  the  nimibers  may  be  more  faAOurable  than  was 
aetuall}^  the  case.  None  the  less  the  apparent  reduction  of  the  general 
incidence  from  45-8  to  28-5  per  cent  affords  food  for  reflection,  and  a 
trial  of  subjecting  every  patient  to  operation,  who  can  be  retained  for 
a  week  in  a  casualty  clearing  station  or  advanced  hospital,  appears 
worth  making. 

The  next  question  is  that  of  the  power  of  prompt  ligature  of  the 
vessels  to  avert  impending  or  commencing  gangrene.  It  has  already 
been  pointed  out  that  pressure  from  extravasated  blood  upon  the 
trunks  or  collateral  branches  can  seldom  be  held  responsible  ;  further, 
that  haemorrhage  extending  between  the  two  laj'^ers  of  muscles  of  the 
calf  is  an  important  element.  In  the  series  there  are  8  cases  bearing 
upon  this  question,  which  seem  Avorthy  of  brief  quotation. 

Case  81. — Admitted  on  third  day,  type  through-and-through  track,  tibial 
pulses  absent,  foot  cool  and  dusky  in  colour.  Ligature  of  popliteal  ailery. 
Definite  gangrene  of  the  tips  of  the  toes,  and  a  patch  on  the  under  surface 
of  the  heel,  developed  ;  a  week  later  the  gangrene  commenced  to  extend, 
and  amputation  of  the  thigh  was  performed. 

Case  82. — Through-and-through  track.  On  the  third  day  the  tibial  pulses 
were  absent,  the  foot  dusky  in  colour  but  not  cold.  The  artery  was  ligatured. 
The  vein  was  uninjured,  and  there  was  no  clot  in  the  popliteal  space.  On 
the  fifteenth  day  gangrene  of  the  foot  was  absolute,  and  amputation  of  the 
thigh  was  performed. 

Case  83. — Through-and-through  track.  Tibial  pulses  absent — limb  cold 
on  the  third  day.  On  the  fourth  day  the  popliteal  artery  was  ligatured. 
The  wound  suppurated  and  general  infection  developed,  necessitating 
amputation  on  the  twenty-first  day. 

Case  84. — Open  wound  of  popliteal  space.  Tourniquet  left  on  for  some 
hours.  On  the  fifth  day  no  tibial  pulses  were  palpable,  and  the  foot  and 
lower  third  of  the  leg  cold  and  anajstlietie.  The  artery  was  ligatured.  The 
vein  was  thrombosed,  and  there  was  no  massive  clot  in  the  popliteal  space. 
Gangrene  progressed,  and  the  limb  was  amputated  on  the  eleventh  day. 

Case  85. — Through-and-through  track.  Fractured  femur  in  lower  third. 
Infected  hicmartlirosis.  On  fifth  day  absent  tibial  pulses  and  incipient 
gangrene  extending  to  mid-leg.  Ligature  of  artery,  localized  haematoma 
of  moderate  size.  The  gangrene  receded,  and  eventually  only  tlie  anterior 
half  of  the  foot  mummified.  The  knee  did  well  with  simple  aspiration. 
The  patient,  an  Indian,  refused  a  Syme's  amputation.     (C  H.  M.) 

Case  86. — Retained  small  shell-fragment.  Arterial  haematoma.  On  the 
fourth  day  the  haematoma  commenced  to  extend,  the  tibial  pulses  were 


VESSELS    OF    THE    LOWER    EXTKEMITY 


241 


absent,  and  the  foot  was  cold  and  marbled.  The  popliteal  artery  was  li>ra- 
tured,  and  the  condition  improved  during  the  next  three  days.  The  patient 
was  sent  to  England,  and  the  further  progress  is  unknown. 

Case  87. — Retained  small  shell-fragment.  On  the  third  day  the  foot  was 
cold  and  pulseless.  The  artery  and  vein  were  ligatured,  and  the  foot  was 
saved. 

Case  88. — Retained  small  shell-fragment.  On  the  fifteenth  day  the 
arterial  hsematoma  commenced  to  extend.  The  tibial  pulses  were  present 
but  feeble,  the  calf  much  swollen,  and  the  foot  cold.  The  artery  and  vein 
were  ligatured,  and  the  foot  was  saved. 

The  first  5  cases  may  all  be  called  failures  ;  the  6th  and  7th  were 
successes,  the  8th  was  a  late  operation,  and  can  scarcely  be  considered 
to  belong  to  the  class,  as  time  for  considerable  compensation  by  the 
collateral  circulation  had  elapsed.  The  small  series,  however,  negatives 
the  idea  that  local  pressure  is  the  chief  cause  of  gangrene,  and  it 
encourages  the  surgeon  neither  to  be  simply  expectant,  nor  to  hurry 
on  to  amputation. 

Ligature. — -Ligature  of  the  vessels  was  performed  in  48  of  the  85 
cases. 


Indication  for  Ligature 

No.  of 

Oiises 

Gangrene 

tatioa           I^'ed 

Primary  hsemorrhage 
Secondary  haemorrhage     .  . 
Pre-operative  gangrene 
Haematoma,  arterial 
Hacmatoma,  arterio- venous          •.  . 
Removal  of  missile 
Wound  of  popliteal  vein  .  . 

19 

8 
5 
6 
5 

4 

1 

8 
3 
5 
1 

1 
1 

5 
.3 
3 

1 

1 
1 

Totals 

48 

19 

12 

2 

In  24  cases  the  artery  alone  was  ligatured  ;  of  these,  11  suffered 
arterial  gangrene  (45-8  per  cent)  and  2  gas  gangrene. 

In  24  the  artery  and  vein  were  ligatured  simultaneoush^ ;  of 
these,  in  6  (25  per  cent)  arterial  gangrene  occvu-red  ;  but  as  in  t^vo  of 
the  latter  incipient  gangrene  was  the  indication  for  operation,  the 
percentage  may  really  be  fairly  considered  16-6  per  cent. 

Tuffier's  Tube. — In  6  cases  a  Tuffier's  tube  was  tied  in.  In  4  of 
these  no  gangrene  occurred  ;  in  1  the  result  is  uncertain.  It  will  be 
observed  that  no  case  is  included  in  which  clotting  did  not  occur 
rapidly.  I  think  this  may  be  partly  due  to  the  fact  that  introduction 
of  the  tube  into  the  distal  end  of  the  vessel  is  often  difficult,  and 

16 


242      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

needs  a  good  deal  of  iiiaiiipnlalioii.  "Sly  own  I'celing  is  tliat  tlu' 
method  is  always  worthy  of  trial  if  siitnre  is  impracticable,  especially 
in  recent  injuries. 

Case  89. — Arterio-vcnous  ha^matoma   explored,    ninth    day.      Tuffier's 
tube  introduced  in  artery  and  vein  tied.     ^Vound  eventually  sui)purated 
Ultimate  result,  discharged  permanently  unfit.     No  record  of  tibial  pulse 
but  foot  was  painful  at  times. 

Case  90. — Retained  shell-fragment.  Arterial  hajmatoma  extension  on 
ninth  day.  Longitudinal  tear  of  artery  and  of  vein,  but  the  latter  was 
thrombosed.  Small  tube  introduced  and  removed  on  the  fourth  day  ;  it 
was  obstructed  in  less  than  twenty-four  hours.  The  leg  and  foot  did  well. 
Five  months  later  the  man  was  reported  to  be  getting  about  on  furlough, 
but  with  some  restriction  of  movements  of  the  knee,  and  with  a  numb  foot 
'at  times.' 

Case  91. — Single  wound,  followed  by  severe  primary  haemorrhage.  Tube 
was  tied  in  on  the  third  day  :  the  absent  tibial  pidses  did  not  return.  The 
condition  of  the  foot  improved,  but  I  have  no  knowledge  of  the  ultimate 
result. 

Case  92. — Arterial  haematoma.  Operation  on  the  eighteenth  day.  The 
artery  was  almost  completely  divided.  A  tube  Mas  tied  in  and  retained 
three  days,  pulsation  returning  in  the  tibial  pulses.  The  patient  made  a 
good  recovery  (section  of  clot  from  tube,  Plate  IV).     (G.  H.  M.) 

In  2  cases  reported  from  casualty  clearing  stations,  pulsation  in 
the  tibials  lasted  in  one  for  forty-five  minutes  only,  and  in  the  second 
the  tube  was  left  for  five  days.  In  neither  of  the  cases  did  gangrene 
supervene. 

Suture  of  Wounds  of  the  Popliteal  Vessels. — In  5  cases  woimds 
in  the  artery  were  sutiu-ed  : — 

Case  93. — Operation  on  sixth  day.  A  long  ragged  wound  closed  by 
vertical  suture  ;  on  the  next  day  the  anterior  pulse  was  good.  The  wound 
of  the  soft  parts  was  an  extensive  one  ;  it  suppurated,  and  the  patient  even- 
tually died.  Thrombosis  of  the  artery  is  probable,  as  secondary  haemor- 
rhage did  not  occur.     No  other  details  are  available. 

Case  94. — Operation  on  seventh  day.  A  ragged  hole  in  the  artery  was 
sutured  vertically.  The  pulses  returned,  and  on  the  thirty-fifth  day  the 
blood-pressure  in  the  leg  was  equal  to  that  on  the  sound  side.  (Lieut. -Col. 
Kidd,  C.A.M.C.) 

Case  95. — Opei'ation  on  the  third  day  for  recurrent  haemorrhage.  A 
lateral  wound  in  the  artery  was  sutured,  and  the  tibial  pulses  returned. 
On  the  eighteenth  day  the  pulses  were  still  retained.  The  blood-pressure 
in  the  injured  leg  was  99,  in  the  sound  one  119.  A  secondary  haemorrhage 
occurred  on  the  twenty-third  day  ;  the  wound  was  reopened,  and  the  vessel 
found  to  be  thrombosed.  A  double  ligature  was  applied,  and  the  patient 
made   a   good   recovery.     (Lieut. -Col.   Kidd,   C.A.M.C.) 

Cfl.se  96. — Operation  for  primary  haemorrhage.  Wounds  on  the  anterior 
surface  of  both  artery  and  vein  sutured.  Three  weeks  later  the  patient 
arrived  in  London  with  a  practically  normal  foot  and  good  tibial  pulses. 


VESSELS    OF    THE    LOWER    EXTREMITY  243 

Ten  days  later  the  pulses  had  disappeared,  but  the  foot  and  leg  remained 
in  good  condition,  with  sli<)ht  a>denia  (1  in.  increase  of  circumference  of 
calf).     (Capt.    Gordon   Taylor.) 

Case  97.  Operation  on  seventh  day.  Arterio-venous  anastomosis  estab- 
lished ;  transverse  wound  of  posterior  surface  of  artery  immediately  above 
bifurcation  sutured  transversely.  Pulses  present  at  end  of  operation  and 
persisted.  Ten  days  after  the  operation  the  blood-pressure  in  the  two  legs 
was  equal  (110  mm.).     (G.  H.  M.) 

Case  98.  Arterial  ha;matoma.  On  the  twelfth  day  the  swelling  in- 
creased, and  the  popliteal  space  was  explored.  A  lateral  opening  in  the 
artery  was  closed  by  suture,  and  the  sac  plicated.  At  the  end  of  a  month 
the  patient  came  to  England,  and  two  months  later  he  was  still  in  hospital 
with  weakness  of  the  muscles  of  the  leg. 

This  small  series  is  suggestive,  as  in  no  instance  did  gangrene 
occur,  and  in  the  death  which  took  place  the  wound  of  the  soft  parts 
was  responsible.  In  Nos.  2  and  5  the  result  was  apparently  ideal ; 
in  Nos.  3  and  6  it  was  good  ;  and  the  same  must  be  said  regard- 
ing No,  4,  although  there  is  no  doubt  the  vessel  eventually  suffered 
thrombosis. 

The  results  recorded  above  speak  in  favour  of  suture  of  the  vessel 
when  the  wound  is  lateral ;  some  evidence  is  offered  in  support  of 
the  use  of  Tuffier's  tubes,  and  also  in  favour  of  a  more  frequent  resort 
to  primary  ligature.  It  is  an  undoubted  fact  that  in  this  series  the 
immediate  results  improved  in  connection  with  two  changes — first, 
a  better  initial  wound  treatment ;  and  secondly,  the  adoption  of 
simultaneous  ligature  of  artery  and  vein. 

Lastly,  with  regard  to  the  operations.  Whichever  method  is 
adopted,  the  central  posterior  incision,  extending  from  1  in.  above  the 
upper  angle  of  the  popliteal  space  to  1  in.  below  the  lower  angle, 
should  alwaj^s  be  used  ;  the  internal  incision  never  gives  sufficient 
access.  The  external  saphenous  vein  must  often  be  ligatured  ;  but 
care  should  be  taken  that  its  communicating  branch  to  the  internal 
saphenous  is  not  injured.  The  internal  popliteal  nerve  should  be 
held  aside,  either  with  a  gauze  or  thin  rubber  loop,  and  not  with  a 
steel  retractor.  Great  care  should  be  exercised  in  freeing  the  nerve 
that  the  anastomotic  chain  accompanying  it  be  not  injured,  as  the 
integrity  of  these  small  vessels  is  of  first-rate  importance  ;  if  for 
any  reason — as  in  removing  a  Tuffier's  tube— the  nerve  be  exposed 
a  few  days  after  the  main  trimk  has  been  obstructed,  a  vessel  compar- 
able to  the  radial  in  size  is  felt  beating  within  the  nerve  sheath.  No 
branch  of  the  main  arterial  trunk  should  be  damaged,  if  possible. 
When  the  injury  to  the  artery  is  in  the  central  part  of  its  course,  and 
the  vessel  is  ligated  and  divided,  care  must  be  taken  to  make  sure 
that  the  open  end  of  the  azygos  articular  branch  is  attended  to,  as 
otherwise  is  may  be  a  source  of  secondary  haemorrhage.      When  the 


244      GUNSHOT    INJURIES    TO    THE    BLOOD-VESSELS 

lower  part  of  the  trunk  needs  to  be  sutured,  the  main  operative 
trouble  is  usually  a  multitude  of  small  veins  entering  the  parent 
trunk,  and  time  is  saved  by  dealing  with  these  promptly. 

It  would  seem  unnecessary  to  emphasize  the  importance  of  not 
allowing  the  knee-joint  to  become  flexed  during  the  early  after-treat- 
ment ;  but  neglect  of  this  elementary  rule  is  much  more  frequent 
than  would  be  expected,  and  leads  to  very  troublesome  after-results, 
and  prolongs  the  period  of  treatmeht  enormously. 

THE     ARTERIES     OF      THE      LEG. 

These  vessels,  little  loved  by  the  candidate  at  an  examination 
in  operative  surgery,  have  acquired  a  no  more  agreeable  reputation 
Avith  the  military  surgeon  when  they  may  happen  to  be  the  seat  of 
a  gunshot  injury. 

A  woimd  of  either  the  anterior  Or  posterior  tibial  artery  might 
be  expected  to  prove  an  accident  of  minor  importance  ;  but  this  is 
far  from  being  the  case.  A  traumatic  aneiu'ysm  of  either  variety 
is  not  a  common  thing  to  meet  with  iti  the  hospitals  on  the  lines  of 
communication  or  at  the  base,  and  they  form  the  smallest  section  in 
the  series  of  cases  under  consideration.  The  number  of  instances 
which  came  under  my  observation  is  indeed  so  meagre  as  to  furnish 
no  opportunity  for  making  any  statistical  remarks  whatever  upon 
them. 

The  reasons  for  this  are  not  far  to  seek.  The  vessels  themselves 
are  not  of  large  size.  Beyond  this,  they  bear  such  a  close  relation  to 
the  bones  of  the  leg  that  vascular  wounds  are  rarely  imcomplicated. 
Even  if  no  fracture  exists,  another  peculiarity — the  fact  that  both 
anterior  and  posterior  tibial  arteries  are  situated  in  spaces  which  are 
especially  apt  to  retain  extravasated  blood  from  a  woimded  artery 
and  thus  to  subject  the  other  tissues  within  the  space,  including  the 
collateral  branches,  to  injurious  pressure — makes  these  injuries  parti- 
cularly dangerous.  The  last  condition,  again,  renders  even  a  moderate 
amoimt  of  gas  formation  in  the  presence  of  an  anaerobic  infection 
a  source  of  early  and  very  acute  danger.  Lastly,  as  a  result  of  the 
large  part  of  the  mass  of  the  leg  which  is  occupied  by  bone,  extensive 
lacerated  wounds  of  an  explosive  character  often  accompany  the 
injuries  to  the  tibial  vessels. 

The  comparative  rarity  of  traumatic  aneurysms,  therefore,  is  to 
be  attributed  to  the  infrequeney  of  isolated  injuries,  the  degree  of 
tension  which  is  apt  to  develop  when  the  arteries  are  woimded,  and 
the  frequency  with  which  the  wounded  vessel  lies  in  a  large  woimd 
which  does  not  offer  conditions  favourable  to  the  formation  of  a  sac. 
The  illustrations  {Fig.  22,  p.  59)  in  the  general  section  of  this  essay. 


VESSELS    OF    THE    LOWER    EXTREMITY  245 

however,  show  that  an  aneurysmal  sac  may  often  be  in  process  of 
formation  when  its  presence  is  not  expected  ;  and  the  fact  that  these 
small  sacs  were  evacnated  together  with  a  large  mass  of  coagiiliim, 
supports  the  description  there  given  of  their  mode  of  development. 

Signs  of  Wounds  of  the  Tibial  Arteries. — The  anatomical  con- 
ditions above  referred  to,  account  also  for  such  special  characters 
as  the  signs  possess.  The  most  common  result  of  a  wound  from  which 
the  blood  does  not  escape  externally  is  the  diffusion  of  the  extravasa- 
tion, either  through  the  greater  part  of  the  compartment  containing 
the  anterior  group  of  muscles ;  beneath  the  fascia  covering  the  deep 
muscles,  or  throughout  the  interspace  between  the  two  layers  of  the 
muscles  at  the  back  of  the  leg.  Thus,  either  a  tense  swelling  of  the 
front  of  the  leg,  or  a  greatly  swollen  calf,  is  developed.  The  pressure 
is  often  such  as  to  involve  more  or  less  the  whole  length  of  the  main 
trunk  ;    hence  the  pulses  at  the  ankle  are  early  abolished. 

It  must  be  remembered  also  that  great  swelling  of  the  calf,  or 
of  the  anterior  region,  respectively,  does  not  necessarily  indicate  that 
the  corresponding  vessel  is  the  seat  of  the  lesion  ;  for  not  infrequently 
the  blood  from  a  wounded  anterior  tibial  artery  may  pass  in  the  line 
of  the  track  made  by  the  missile  through  the  interosseous  membrane, 
or  the  reverse  state  of  things  may  take  place  when  the  posterior  tibial 
is  wounded.  Again,  either  form  of  swelling  of  the  leg  may  develop 
in  connection  with  a  wound  of  one  of  the  branches  of  the  trunks,  and 
may  exercise  sufficient  pressure  to  obliterate  the  pulse  in  just  the  same 
way  as  if  the  main  vessel  were  the  seat  of  injury. 

The  diffuse  h?cmatomata  formed  in  this  manner  may  pulsate  at 
first,  and  later  become  solid  as  a  result  of  coagulation  of  the  large 
collection  of  blood. 

Under  these  circumstances,  it  must  be  realized  that  the  diagnosis 
of  the  existence  of  a  wound  of  the  main  vessel,  and  location  of  its 
site,  are  not  always  easy.  The  readiest  and  surest  method  of  investi- 
gation in  case  of  difficulty  is  by  auscultation,  as  the  characteristic 
murmurs  of  either  an  arterial  or  an  arterio- venous  injury  are  rarely 
absent.  I  have  detected  a  wound  of  the  peroneal  artery  by  this 
method  when  the  anterior  and  posterior  tibial  arteries  had  both  been 
tied  in  a  large  wound  ;  in  regard  to  this  case — in  Avhich,  by  reason 
of  the  free  exit  which  existed  for  the  bleeding,  no  tension  had 
developed— it  is  remarkable  that  only  after  ligature  of  the  third  artery 
did  signs  of  gangrene  develop.  In  the  case  of  multiple  woiuids  in 
the  leg,  the  existence  of  a  systolic  murmur  in  the  cardiac  region  may 
also  help  in  making  a  diagnosis.  A  conveyed  murmur  from  this 
region  is  present  in  something  like  a  third  of  all  arterial  wounds. 

In  contrast  with  the  above  description,  a  small  well-localized 
traumatic   aneurysm    may    develop ;     and   in    one    case    I    saw   two 


246     GUNSHOT    INJURIES    TO    THE    BLOOD-UESSELS 

artcrio-vcnons  communications,  -within  two  inches  of  each  other, 
formed  between  the  posteror  tibial  artery  and  veins  at  the  lower 
third  of  the  leg.  A  still  more  striking  example  of  a  localized  lesion 
was  a  definite  arterial  hacmatoma  in  connection  with  the  external 
plantar  artery,  the  wovmd  in  the  vessel  being  partly  blocked  by  the 
external  plantar  nerve. 

Prognosis  and  Treatment. — I  am  sorry  to  be  unable  to  give  any 
estimate  of  the  mniiber  of  limbs  which  have  been  lost,  or  the  number 
of  deaths  which  have  occurred,  consequent  on  wounds  of  these 
arteries ;  but  I  know  it  to  have  been  a  large  one,  quite  incom- 
mensurate with  the  size  of  the  vessels  involved.  This  question  is  of 
importance  only  with  regard  to  the  primary  treatment  of  the  injuries, 
and  points  to  the  necessity  of  rajjidly  relieving  the  tension  of  the 
limb  by  incision  and  direct  treatment  of  the  wound  in  the  vessel. 
In  the  siu'gery  of  this  war,  moreover,  injury  to  no  vessels  has  more 
clearly  exemplified  the  sinister  influence  of  interference  with  the 
main  blood-supply  on  the  occurrence  of  anaerobic  gangrene  ;  hence 
all  such  injuries  are  to  be  regarded  with  suspicion. 

Secondary  haemorrhage  is  very  common,  both  as  a  result  of 
contusion  and  throinbosis,  of  non-penetrating  wounds  of  the  arteries, 
and  following  infection  ;  and  in  no  situation  is  it  more  necessary  to 
deal  promptly  with  even  insignificant  escapes  of  blood  in  the  course 
of  treatment  of  the  cases. 

Little  need  be  said  regarding  the  treatment  of  false  aneurysms 
of  either  variety.  The  ordinary  lines  laid  down  in  the  general  section 
suffice  to  meet  any  case.  It  ma^^,  however,  be  pointed  out  that 
when  a  wound  of  the  anterior  tibial  artery  is  situated  in  close 
proximity  to  the  spot  at  which  the  vessel  pierces  the  interosseous 
membrane,  the  surgeon  must  be  prepared  for  difficulty  in  securing 
the  upper  end  of  the  artery,  and  even  a  separate  posterior  incision 
may  prove  to  be  necessary.  Again,  when  a  large  collection  of  coagu- 
lated blood  is  deposited  between  the  layers  of  muscles  of  the  calf, 
a  central  incision  is  preferable  to  the  classical  lateral  incision  for 
^securing  the  posterior  tibial  artery. 


247 


INDEX. 


of 


123,   159, 
13,   58,   02^ 


AIR,  entry  of,  into  veins 
Anaerobic     gangrene — effect     of 
thrombosis  in  spread  of 
Anastomosis  of  arteries  .  .        169, 

Anatomical     conditions     influencing 
occurrence      of     injuries      to 
individual  blood-vessels 

—  —  favouring     the     occurrence 

secondary  haemorrhage 
Aneurysm  complications 

—  in  amputation  stumps 

—  infection  of  . . 

—  murmurs  in .  . 

—  pressure  signs  due  to 

—  secondary  haemorrhage  from 

—  septic 

—  signs  and  symptoms  of 
— •  spontaneous  cure  of 

—  tardy  development  of     . 
■ —  traumatic,  treatment  of    . . 

—  —  aneurysmal  varix 
• — ■  —  arterial  aneurysm 

—  —  arterial  ha9matoma 

—  —  arterio-venous  aneurysm 
Aneurysmal  sacs 
— ■  —  inclusion  of  nerves  in  wall  60,  170, 

—  —  in  apex  of  lung  . .  . .  61, 

—  —  loculation  of       .  .  .  .  .  .    • 

—  —  ossification  of  wall 

part     taken     by     surrounding 

tissues  in 

—  —  plication  of 

—  —  spontaneous  cure  of     .  .  61, 

—  varix,  histological   details  of  bond 

of  union 

—  —  post-operative  recurrence 

—  —  secondary     changes     in     distal 

circulation 
— •  —  signs  of  . . 
spontaneous  healing  of     78,   81, 

—  —  treatment  of      . . 
Angeiorrhaphy  .  . 

—  indications  for 

—  plication  of  aneurysmal  sac        108, 

—  results  of 

— ■  reconstruction  of  arterial   wall    by 


—  {see  also  suture  of  individual  vessels) 
Angiotic  paralysis 

Aorta,   abdominal,  perforation  of      26, 
• —  —  spontaneous  repair  of  perforation 

—  thoracic,  arterio-venous  lesion  of. . 
bullet  wound  of 

retention  of  spherical  bullet  in 

Archek,  Major  Stoney 


183 


14 

230 


36 
64 
68 
67 
63 
65 
65 
68 
63 
209 
,  71 
82 
85 
84 
82 
85 
58 
210 
116 
61 
61 

62 
171 
161 

76 
174 

78 
81 
117 
85 
106 
107 
171 
108 

108 

56 
119 

26 
115 
114 
113 


PAGE 

Arterial  hsematoma,  mode  of  develop- 
ment    .  .           . .           . .           . .  57 

—  —  part     taken     by     surrounding 

tissues  in        .  .           .  .           .  .  62 

—  —  progress  and  complications      . .  64 

—  —  signs  of  .  .           . .           .  .           .  .  03 

treatment  of      . .           .  .           .  .  82 

—  stupor            14,  139 

—  wall,  effect  of  stretching  on          .  .  9 
Arteries,  effect   of   local    occlusion   on 

peripheral  pulse          .  .           .  .  87 

—  primary  ligature  of  . .           . .           . .  6 

Arterio-venous  aneurysm        . .           .  .  68 

— •  —  arterial  nature  of  sacs             .  .  75 

complications  attendant  upon  73 

effects  of,  on  distal  circulation  75 

—  —  gangrene  resulting  from  proxi- 

mal ligature  . .           .  .           .  .  102 

relative  frequency  of  occurrence  69 

—  —  signs  and  symptoms  of .  .           ..  73 

—  —  treatment  of      . .           .  .           .  .  85 

—  —  varieties  of  arrangement  of  sacs 

to  vessels        .  .           .  .           . .  69 

Athanassio-Beististy  and  Meige  87,  91,  93 
Auscultation,  importance    of,  in    dia- 
gnosis of  arterial  lesions          .  .  64 
Axillary  artery  . .           .  .           . .           .  .  189 

—  —  anatomical  conditions  affecting 

injuries             . .           .  .           .  .  189 

—  —  contemporaneous  nerve  injuries  190 

—  —  eifects  of  occlusion        .  .           .  .  194 

—  —  hasmothorax    complicating    in- 

juries to           . .           .  .           . .  191 

—  —  implication  of  nerves    . .           .  .  190 
— •  —  injuries  to  branches      .  .           .  .  193 

■  methods  of  treatment  .  .           .  .  196 

nature      and      distribution      of 

injuries  of       .  .           . .           .  .  189 

participation  of  nerves  in  forma- 
tion of  wall    . .           .  .           .  .  201 

—  —  prognosis  and  treatment         . .  194 

—  —  signs  and  symptoms  of .  .           ..  191 

—  —  spontaneous  obliteration          .  .  190 

suture  of             . .           . .           . .  197 

Tuffier's  tube 197 

B 

Bashford,  Captain  E.  F.  8,  10,  14,  25,  77 

Bazett,  Captain    . .    . .    . .  Ill 

Blood-press\rre  :   fall  attending  arterial 

injuries    . .           . .           . .           .  .  41 

presence  of  aneurysms  de- 
pendent on  occlusion  bv 
hgatui-e      .  .           . .           88,  244 

in  femoral  injuries        .  .           . .  224 

Blood  transfusion          . .           .  .           . .  38 


248 


INDEX 


BowLBY,  -Sir  Antifonv,  piimary  Ufia- 

ture  of  arteries  .  .           .  .           .  .  f> 

Brachial  artery,  diagnosis  of  injury  to  20:} 

—  —  embolism  of       .  .           .  .           .  .  187 

panirrcue  following  occlusion   .  .  205 

.  liiLrli  di\ision  of .  .           .  .            .  .  205 

incomplete  lesion           .  .           .  .  203 

—  —  nature      and      distribution      of 

injuries            . .          . .          . .  201 

nerve  complications      ..           ..  203 

sutura      . .           . .           . .           . .  204 

Bbentano,  wound  of  aorta    . .          . .  2(1 

Bubbling  thrill,  delay  in   development  74 

—  —  diffused  charaqter          .  .           .  .  74 

Bullet,  pointed..           ..           ..           ..  4 

Burrows,  Major  H.  ..      56,   91,    145,  164 
Burrows,    H.,    and    Stott,    A.    W., 

muscular  iscliEemia        .  .           .  .  90 

Butler,  Lieut. -Colonel       ..          59.  133 


Cardiac  dilatation       .  .  .  .  40, 

—  murmurs       

conveyed 

—  — •  hffimic 

mode  of  transmission  .  . 

Carotid  artery  :    aneurysmal  varix     .  . 

—  . —  arterial  hffiraatoma 

—  —  arterio-venous  aneurysm 

choice  of  method  of    treatment 

;  complications     of    wounds     of, 

anaerobic    infection,    second- 
ary hasmorrhage 

contusion 

diagnosis  of  injuries  to.  . 

—  — •  external,  injuries  to  branches.  . 

—  —  haemorrhage  from 
— •  —  indications  for  ojaeration 

—  —  mode  of  operation 

—  — ■  nature      and      distribution      of 

injuries 

prognosis  of  injuries 

— •  — ■  suture  of  vessels    147,    171,    172, 

173, 

—  —  treatment   of  injuries  to,  cases 

illustrating 

Tuffler's  tube     .  . 

Carrel,  Dr.  Alexis    . .  . .  103, 

Cerebral      complications      of      carotid 

injuries 

diagnosis  of 

effect    of    ligature    of    common 

carotid  upon  149,    158, 

—  —  embolism 

—  — -  explanation  of   .  . 

mode  of  onset  . . 

•  nature  of  symptoms    .  . 

prognosis 

Circulation,  general,  effect  of  arterial 

injuries  upon 

—  —  maintenance      after      complete 

severance  of  vessel  .  . 
Circumflex  arteries  of  thigh     .  . 

—  iliac  artery  . . 
Clavicle,  division  of,  in  operations  on 

subclavian  artery 
Comparison  of  lesions  caused  by  shell 
fragments  and  bullets  .  . 


42 

48 

48 

48 

53 

101 

158 

160 

174 


132 
127 
128 
164 
130 
164 
160 

127 
161 

174 

169 
169 
110 

137 
156 

165 
140 
139 
156 
139 
156 

40 

125 
215 
123 

188 


Control    of    hajmorrhage    by    plug    of 

soft  tissues  and  by  foreign  bodies  27 

Contusions  of  the  blood-vessels          . .  8 

— •  —  histology.  .          .  .           .  .           .  .  10 

— ■  —  wide  extent  of  lesions  .  .           .  .  16 

Corner,  M.\j<)R  Edred   M.    . .         205,  225 

CowELL,  Captain  E.   M.         ..           ..  211 

Crymble,  Captain       .  .          .  .          . .  44 

Curry,  Captain  Alan            ..          ..  140 

Gushing,  Colonel  Harvey              . .  176 

D 

Delay  in  development  of  aneurvsms 

^13,   62,   71 
Diaphragmatic  hernia  .  .  .  .      120 

Disorder  of  nerve  function  in  vascular 

injuries    .  .  .  .  .  .  .  .        55 

Disorderly  action  of  the  heart.  . 
Distribution   of   arterial   injuries   over 

individual  vessels 
Drummond,  Major  Hamilton 
Duval,  Dr.  Pierre 
Dysphagia    and    dyspnoea    in    carotid 

injuries    .  . 


44 


105 

169 


105 


Effect  of  local  occlusion  of  arteries  on 

peripheral  pai'ts              .  .           .  .  87 

—  stretching  on  arterial  wall  .  .  9 
Elliott,  Lieut. -Colonel  T.  R.  4,  117 
Elliott  and  Henry  ..  ..  67,  118 
Embolism            . .           .  .           .  .              13,   93 

—  brachial          .  .           . .           .  .           .  .  187 

—  cerebral  .       . .          . .          . .          . .  143 

—  as  a  cause  of  gangrene       .  .           . .  96 

—  popliteal         211 

Entry  of  air  into  veins             . .           . .  183 

Exophthalmos,  pulsating         .  .           .  .  129 

Exploratory  incisions,  need  for  freedom  99 


Femoral  artery,  after-results  of  injury 

to,  or  occlusion  of      .  .           .  .  223 

—  — ■  aneurysm,  false .  .          .  .           .  .  220 

—  —  anem-ysmal  varix          .  .           .  .  221 
— •  —  arterial  haematoma       .  .           . .  220 

—  —  arterio-venous  aneurysm          .  .  221 
— •  —  circumflex  branches      .  .           .  .  215 

—  —  complications,  relative  frequency 

in  arterial  and  arterio-venous 

lesions  respectively   .  .           .  .  73 

—  —  deep  femoral  artery      .  .           .  .  214 

—  —  diagnosis  of  injuries  to  branches  215 

—  —  gangrene   following   injuries   or 

occlusion          . .           .  .           .  .  219 

—  —  general    lines    of    treatment    of 

injuries             .  .           . .           .  .  227 

•  modes  of  operation       .  .           . .  228 

— ■  —  mortality      attendant       upon 

injuries             .  .           .  .           .  .  217 

—  —  hatm-e      and      distribution      of 

injuries             .  .           .  .           .  .  208 

—  —  prognosis     and     treatment     of 

injuries             .  .           .  .           .  .  217 

•  results  of  operations  for  ligature  218 

—  —  signs  and  symjDtoms  of  injury  212 
suture      . .           .  .           . .           .  .  225 


INDEX 


249 


Fomoral  artery,  tlirombosis      .  .      8,   10, 

—  — •  Tuffier's  tubes    .  . 
Femoral  vein,  isolated  injuries  of 
FiNLEY,  Lieut. -Colonel        ..  ]4.'{, 
Foreign    bodies    impacted    in    blood- 
vessels 

—  • —  axillary    .  . 

—  —  carotid     .  . 

— aneurysm 

iliac  vessels         .  .  .  .  29, 

—  —  popliteal .  . 
— •  —  thoracic  aorta    .  . 
■ —  —  travelling  in  vessels 
Fbazee,  Captain  J.     .  . 
FuLLERTON,  Colonel  Andrew 


'ACiE 

208 
226 
230 
144 

IC) 

IG 
140 

70 
115 
128 
113 
15,  28 
226 

15 


183,   224, 


122, 

general 


225 
94 

14 

96 
94 

240 

96 
96 
94 

104 

40 
126 
182 
232 

27 


Gabe,  Captain.. 
Gangrene,  anseinic 

—  anaerobic,  effect  of  thrombosis  in 

spread  of 

—  conditions  which  favour     .  . 

—  effect  of  interval  on  occurrence  of 
ligature   of   artery   in   checking 

220, 

—  embolism  as  a  cause  of 

—  extent  of,  after  arterial  occlusion 

—  frequency  of  occurrence     .  . 

—  influence  of  simultaneous  occlusion 

of  artery  and  vein  upon     96,  101. 
General  circulation,  effect    of    arterial 

injuries  upon 
Gluteal  aneurysm 
Gray,  Dr.   Ronald 
Greaves,  Captain 
Greenfield,  Captain  J.  G. 
Gregory,  Captain  H.  C. 
GuNN,  Colonel  J. 
Gunshot    injuries    to    vessels, 

treatment  of       .  .  .  .  .  .        97 

—  exploratory  incisions  for      .  .  .  .        99 
Guthrie,  Mr.    ..          ..          ..          2,   8,   13 

H 

Hemorrhage,  general  treatment  of .  .  38 

—  internal  .  .  .  .  .  .  .  .  30 

—  local  treatment        .  .  .  .  .  .  31 

—  —  —  primary  haemorrhage  31,  34 

—  —  —  recurrent       .  .  .  .  .  .  35 

— secondary      .  .  .  .  .  .  35 

—  physical  signs  of      .  .  .  .  .  .  30 

—  spontaneous  cessation  of    .  .  .  .  31 
■ —  symptoins,  general.  .           .  .  .  .  30 

—  temporary    control   of,    by    plug  of 

soft  tissues  or  by  foreign  body  27 

—  transfusion  of  blood            .  .           .  .  38 

—  —  of  gum  saline      .  .           .  .           .  .  3  J 

Hemothorax,  axillary  injuries            .  .  191 

—  brachial  injuries       .  .           .  .           .  .  202 

—  source  of  blood  in  -_           .  .           .  .  118 

- —  subclavian  injuries.  .           .  .           .  .  177 

Hartley,  Captain       .  .          . .          .  .  10 

Heart,  disorderly  action  of       .  .           .  .  44 

Hernia,  diaphragmatic              .  .           .  .  120 

Hey,  Captain  W.  H.,  primary  ligature 

of  arteries  .  .  .  .  .  .  6 

High  explosives  .  .  .  .  .  .  4 


Histological    changes    in    contiiHi(jn    of 

vessels              .  .           .  .           .  .  H 

arterio-venous  unions   .  .           .  .  77 

Holmes,  Colonel  Gordon     ..          ..  J  43 

Hope,  Major  C.  W.   M.          ..            10,  225 

Hunter,  John              ..          ..          ..  101 

Hutchinson,  Lieut. -Colonel           ..  J  45 

Hypoglossal  nerve,  injuries  to             . .  137 

I 

Iliac     vessels,       common,      con:i2:)Iete 

severance  of            .  .           .  .  123 
contusion  of               .  .           .  .  9 

—  — ■  —  retained   bullets  in..           ..  115 

—  signs  of  injury  to  iliac  vessels  122 

external 122 

—  —  —  arterial  hsematoma               .  .  123 
— arterio-venous  aneurysm    .  .  123 

—  —  internal   .  .           .  .           .  .           .  .  122 

—  —  —  arterial  hajinatoma.  .           .  .  125 

—  —  —  ligature  of,  for  haemorrhage 

from  buttock         .  .           .  .  126 

—  —  jDrognosis    of    injuries    to    iliac 

vessels  .  .          .  .           .  .           .  .  125 

—  —  spontaneous  healing  of  injuries 

to  iliac  vessels            .  .           .  .  125 

—  — ■  treatment    of    injuries    to    iliac 

vessels  .  .          .  .           .  .           .  .  125 

Increase  of  knowledge  gained  in  Great 

War          1 

Inferior  thyroid,        arterio-venous 

aneurysm             .  .           . .           . .  130 

Innominate  artery,  aneurysmal  varix  116 

—  —  arterio-venous    aneurysm         ..  116 

—  —  ligature  of            .  .           .  .           .  .  184 

—  —  spontaneous  healing  of  varix.  .  117 
Inspiration,  effect  of  on  arterio-venous 

aneurysms  at  root  of  neck       . .  158 

Internal  mammary       .  .           .  .           .  .  118 

Interosseous  artery  of  forearm            .  .  206 
Ischaamia,  ixiuscular      .  .           .  .               87.   89 


Johnston  and  Freyer  . .  . .  26 

Jones,  Major  Littler  . .  . .  61 

K 

Kelly,  Captain  Fitzmaurice  147,  192 

Keynes,  Captain  G.  L.  . .  .  .  141 

KiDD,  Lieut. -Colonel  .  .  226,  242 

Knaggs,  Major  La WFORD  ..  ..  61 


Lateral  anastomosis  of  arteries     169 
Lee-Metford  and  Mauser  bullets 
Leriche  and  Heitz     .  .  56,   92 

Ligature  of  arteries,  proximal,  indica- 
tions for  .  .  .  .  I 

—  —  primary    .  . 
IDrovisional 

—  —  with    simultaneous     ligature   of 

vein 


230 

3,   19 

139 

2,  37 
6 

97 

101 


M 

McIlwaine,  Captain  .  .  .  .  44,   52 

Manchurian  campaign,  bullet  injuries  in     3 


250 


INDEX 


PAOK 

Martin,  Captain          . .          .  .  .  .      213 

Matas,  Dr.  R.  ■ 70,  81 

IMeclinstinal  hajiiiorrhage  ..      118 

Medical  Research  Committee  .  .    4,  5 

Mennell,  Captain  Z.             .  .  .  .      201 

Middle  cerebral  artery  embolism  143,    146 

— thrombosis    ..           ..  142,    147 

Morgan,  Captain         ..          ..  ..      119 

MuMFoRD,  Captain  W.  G.     . .  23,  59 

!Muscular  ischa^mia                     .  .  87,   89 

N 
Nerves,  disorder  of   function   accom- 
panying vascular  lesions 

—  effect  of  associated  injury  in  lesions 

of  axillary  vessels 

—  injuries  to  brachial  plexus    137,  178, 

—  —  to  hypoglossal     .  . 
to  spinal  accessory 

to  sympathetic  .  . 


55 

190 
189 
137 
137 
136 


—  —  to  \'agus 


80,  134,  135,  161,  170 


Occlusion  of  arteries,  association  with 

lesions  of  nerves         .  .           .  .  87 
effect      on      peripheral      blood- 
pressure           .  .           .  .           .  .  88 

loss  of  volume  in  limbs  following  88 

muscular  ischasmia  following  .  .  89 

results  of             .  .           .  .           .  .  87 

return  of  distal  pulse  after       .  .  88 

trojjhic  changes  following         .  .  93 

Oliver,  Captain           . .          . .          . .  80 

Ophthalmic  artery        .  .           .  .         129,  138 

Oppel,  W.  a 102 

Osler,  Sir  William   . .  . .  47,   78 

Ossification  of  aneurysmal  sacs           .  .  61 

OzANNE,  Major            . .          . .          .  .  197 


Paralysis,  angiotic      .  .          . .          . .  56 

Peninsular  AVar               .  .           .  .           .  .  3 

Periphei'al    blood-pressure    after    local 

occlusion  of  arteries      .  .           .  .  224 

— •  pulse,     retention     after     complete 

severance  of  vessel    ..           ..  171 

return  of,  after  local  occlusion  88,  223 

Perivascular  sympathectomj'               .  .  5f) 

Pistol-shot  bruit  in  arteries     ..           ..  51 
Popliteal    artery,    arterial    hasmatoma 

\.            and  false  aneurysm  .  .           . .  234 

—  —  aneurysmal  varix           .  .           .  .  236 

—  —  complications  of  injury  to       .  .  233 

—  —  contusion  of       .  .           .  .           .  .  231 

—  —  delay  in  development   of  aneu- 

rysms of          .  .           . .           . .  235 

gangrene    following   injuries    or 

occlusion  of    .  .           .  .           .  .  236 

—  —  ligature    of,    for    pre-operative 

gangrene          . .           . .           .  .  240 

—  —  modes  of  operation  upon       .  .  243 

—  —  nature      and      distribution      of 

injuries  of        .  .           .  .            .  .  230 

—  —  primary  ligature              .  .            .  .  239 

—  —  prognosis  and  treatment           ..  238 

—  —  signs  and  symptoms  of  injury  to  233 

—  —  suture  of  woiuids  of      . .           .  .  242 


PAGE 

Popliteal  artery,  thrombosis  of            .  .  231 

Tutfier's  tube 241 

Popliteal  vein,  isolated  injuries  of      . .  234 

Prixgle,  Captain        . .          . .          . .  9 

Portal  vein,  wound  of  .  .           .  .           . .  22 

Profunda  artery  of  thigh           . .           .  .  214 

Provisional  ligature  of  vessels              . .  97 

R 

Radial    artery..          ..          ..          ..  206 

Repair  of  wounded  vessels       .  .           .  .  24 

Retroperitoneal  infection          ..           ..  119 

RojiANis,  Captain        .  .           .  .           .  .  22 

Roval  CoUege  of  Surgeons  61,  113,  115, 

119,  120,  126 


Santos,  Captain 

Sargent,  Lieut. -Colonel  Percy 

Secondary  ha?morrhage 

—  —  from     arterial     haematoma 

130, 

from  visceral  arteries  . . 

Sencert,  Dr.    . . 

Septic  aneurysm 

Shattock,  Mr.  S.  G.     .  . 

Shelle\%  Captain  L.  W. 

Signs    and    symptoms    of    injuries 

blood-vessels 
Simultaneous   ligature   of   artery   and 

vein 
Smith,  Captain  Clementi 
Smith,  Colonel  Maynard    . . 
South  African  War 
Spinal  accessory  nerve,  injuries  to 
Spontaneous    healing    of    woiuids 

vessels 

—  cure  of  aneurysm    .  .  123, 
Stevenson,  Subgeon-General 


..  198 
61 
35 

65, 

134,   135 

..      119 

18 

68 

15 

5 


to 
30, 


40 

101 

59 

.  .       145 

3 

..      137 

of 

26,  29 

159,  209 

75 


Stokes,  Captain  Adrian    9,  21,  22,  24,  114 


Stokes,  Sir  William 
Stone,  Captain 
Stopford,  Dr.  J.  B.    .  . 
Subclavian  artery,  arterial  hematoma 

180 

—  —  arterio-venous  aneurj'^sm 

—  —  cases  illustrating  injiu-y  to 

—  —  diagnosis  of  injuries      . . 

—  —  gangrene   following   ligature   of 

—  —  embolism  in  bracliial  artery   .  . 
hsemothorax  complicating  injuries 


to 


27 
42 
93 

186 
183 
180 
179 
186 
187 

177 

178 


plexus 


implication  of  nerves 

injuries      to      brachial 

accompanying 

—  —  modes  of  opei'ation  upon 

—  —  mortality  attendant  upon  injurie 

to  

•  nature      and      distribution      of 

injuries  to 

Subscapular  artery 

Superior  thyroid  artery 

Symonds,  Colonel  Charters,  im- 
pacted foreign  body  in  axillarj' 
artery 

Sympathetic,  cervical,  injuries  to 

Symjitoms    and    signs    of    injuries    to 

blood-vessels       . .  .  .  30,  40 


178 
187 

187 

176 
193 
135 


16 
136 


INDEX 


251 


Temporary  control  of  hfemorrhage  by 

foreign  bodies    .  .           .  .           .  ,  27 

Thrombi,  absorption  of  ..  ..  12 
Tlirombosis     following     contusion     or 

wound  of  arteries      ".  .           .  .  11 

—  —  influence  on  anaerobic  infections  14 

—  —  injuries  to  veins  .  .  .  .  l-J- 
Tibial  arteries,  importance  of  injuries  244 

—  —  prognosis  and  treatment           .  .  240 

—  —  rarity  of  traumatiq  aneurysms  244 

—  —  signs  and  symptoms  of  injuries  to  245 

Todd,  Dr.  T.  W 93 

Tourniquet,  use  of       .  .  .  .  32,   97 

Transfusion  of  blood     .  .           .  .           .  .  38 

Ti'ansperitoneal  ligature  of  iliac  vessels  125 
Travelling  foreign  bodies  in  vessels  15,  28 
Treatment     of     gunshot     injuries     to 

vessels,  general  lines  97 

—  —  —  —  exploratory  incisions  for  99 
Trophic  changes  in  foot            . .           .  .  225 

in    hand . .           .  .           v  .           . .  91 

TuFFiER,  Prof.,  arterial  anastomosis 

tubes 109 

—  —  —    —  arterial  bruit  caused  by 

presence  of      . .           .  .  51 

—  —   —    —  bond  of  tissue  replacing  29 

—  —  —  —  results  of  use      ..           ..  110 

—  (See  also  under  Special  Vessels.) 


U 


Ulnar  artery     .  . 


.      206 


Vagus  nerve,  injuries  to    80,  134,  135, 

161,    170 


Van   Kend,   simultaneous   litrnt iii-e   of 

artery  and  vein  103 

Vascular  murmurs         .  .  4  0 

—  —  factors  influencing  50 

—  —  general     .  .           .  .           .  .           .  ,  .51 

local         49 

Veau,  ViANNEY,  Lacoste,  and  P'erriek  14 

Veins,  entry  of  air  into  .  .           .  .           .  .  183 

—  great,  wounds  of       .           .  .           .  .  I2f» 

—  histology  of  wounds  of  .  .  24 
Vertebral  artery  .  .  .  .  176 
Visceral  arteries,  lia'inorrhage  from   ..  119 


W 

Walker,  Captain  H.  B.          . .  . .  141 

Wallace,  Major-General     .  .  . .  227 

Watson,  Colonel  C.  Gordon,  19,  68,169 

Whale,  Captain  Lawson       .  .  . .  141 
Wounds    of    the    arteries,    absence    of 

explosive  lesions        ..  ..  15 

—  anatomical  characters         .  .  .  .  15 

—  complete  division    . .           .  .  .  .  20 

—  lateral            .  .           .  .           . .  . .  15 

—  perforations .  .           .  .           .  .  . .  18 

—  spontaneous  healing  of      .  .  26,  29 

—  veins .  .           .  .           ; .           .  .  .  .  22 

—  portal  vein  .  .           .  .           .  .  .  .  22 

histological  characters  .  .  24 

Wright,  Sir  Almroth,  absorption  of 

thrombi                . .           . .  .  .  12 


Young,  Dr.  Matthew  . .  . .  5 

Young,  Captain  ..  ..  ..      119 


DATE  DUE 


HARfl 


1995   MAR 


2  9  1995 


JiERJi^^3& 


•s 


the 
:,  as 


RD156 


M282 


^J.r-?. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  156  M282  C.1 

On  gunshot  iniuries  to  the  bloorl-vessels 


2002103079 


